Every finding on record at Highland Manor of Mesquite Rehabilitation LLC

Based on interviews, record review, and facility policy review, the facility failed to ensure four of five residents reviewed (Resident (R) 1, R12, R20, and R79) were provided with written information or education regarding advance directives and the right to formulate an advance directive to ensure their desired level of medical care was known in the event they were unable to direct care on their own. This failure had the potential to affect the ability of cognitively intact residents to direct their care.Findings include:R1 was admitted on [DATE] with diagnoses including transient cerebral ischemic attack, chronic obstructive pulmonary disease (COPD), asthma, altered mental status, sleep disorder, and Alzheimer's dementia. R1's admission Record noted: Advance Directive: Do Not Resuscitate. (Allow Natural Death). Comfort-Focused Treatment. No IV (intravenous) fluids. No artificial nutrition of feeding tube.R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/11/2026 revealed a Brief Interview for Mental Status (BIMS) score of indicative of being cognitively intact.R1's electronic medical record (EMR) showed a completed Physician's Order for Life Sustaining Treatment (POLST) form, which was a cardiopulmonary resuscitation directive and not an advance directive. R1's admission Packet did not show any education included regarding an advance directive.R12 was admitted on [DATE] with diagnoses including acute chronic congestive heart failure (CHF), COPD, type 2 diabetes, acute respiratory failure, and chronic kidney disease. R12's admission Record noted: Advance Directive: DNR [Do Not Resuscitate] - Selective Treatment - Artificial nutrition/feeding tube trial.R12's admission MDS with an ARD of 02/06/2025 revealed a BIMS score of 14 indicative of being cognitively intact.R12's EMR revealed R12 had a POLST; however, no advance directive or documentation of education regarding an advance directive was located.R20 was admitted on [DATE] with medical diagnoses including acute and chronic respiratory failure, urinary tract infection, metabolic encephalopathy, hypertensive heart disease, dementia, and heart failure. R20's admission Record noted Advance Directive: Do not resuscitate (Allow Natural Death) Comfort-Focused Treatment. No artificial nutrition or feeding tube.R20's admission MDS with an ARD of 01/16/2026 revealed a BIMS score of 14 indicative of being cognitively intact.R20's EMR revealed R20 had a POLST; however, no advance directive or documentation of education regarding an advance directive was located.On 04/10/2026 at 1:21 PM, when queried if the facility had explained or provided written education regarding advance directives (explained examples were a living will, Healthcare Power of Attorney (HCPOA), or possibly a Five Wishes form), R20 thought they had a living will, but the facility had not asked about it and had not provided any education.R79's was admitted on [DATE] with medical diagnoses including COPD with exacerbation, acute respiratory failure with hypoxia and hypercapnia, pulmonary hypertension due to lung disease and hypoxia, and heart failure.R79's admission Record noted Advance Directive: DNR (Do Not Resuscitate) Comfort Focused Treatment. No artificial nutrition or feeding tube. No IV fluids.R79's admission MDS with an ARD of 03/12/2026 revealed a BIMS score of 15 indicative of being cognitively intact.R79's EMR revealed R79 had a POLST; however, no advance directive or documentation of education regarding an advance directive was located.On 04/10/26 at 1:21 PM, R79 was queried if the facility had asked about advance directives and responded No. When asked if the facility had explained or provided written education regarding advance directives and possibly offered to assist R79 if they would like to set one up, R79 replied, Nobody has ever offered. On 04/09/26 at 1:10 PM, the Regional [NAME] President of Operations (RVPO) stated the facility was unable to find anything regarding advance directive education for the four residents. The RVPO stated the Social Worker (from another facility) was there who knows his stuff. We think [name of the former Social Worker] didn't really understand the difference between a POLST and an advance directive. We will ensure we do some education. The RVPO confirmed the facility had no documentation of resident education regarding advance directives. The facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, implemented 04/11/2025, revealed: . Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State) relating to the provision of health care when the individual is incapacitated . 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure oxygen concentrator filters were free of dust and heavy buildup of lint for three of four sampled residents (Residents (R) 62, R5, and R79) out of a total sample of 24 residents. This failure had the potential for the residents to have an increased chance of unnecessary respiratory treatments and/or infection.Findings include: R62's was admitted on [DATE] and diagnoses including bradycardia (slow heart rate), hypoxemia (low blood oxygen level), and atrial fibrillation. R62's Physician Orders dated 03/23/2026 documented Oxygen at 2 L [liters] via NC [nasal cannula] to maintain SPO2 [Peripheral Oxygen Saturation] greater than 90% as needed for SOB [shortness of breath] related to hypoxemia. On 04/07/26 at 2:00 PM, R62 was lying in bed sleeping and wearing oxygen via a nasal cannula. The oxygen tubing was connected to the oxygen concentrator which was set at 2 liters per minute (LPM). The black oxygen cabinet filter located on the left side of the concentrator was observed to be very dirty and full of a thick buildup of white lint. On 04/08/26 at 9:00 AM, R62 was lying in bed and wearing oxygen via nasal cannula. The same black oxygen cabinet filter located on the left side of the oxygen concentrator as the day before was still dirty and full of white lint. On 04/08/26 at 12:00 PM, R62 was lying in bed awake and watching television. R62 was observed wearing oxygen via nasal cannula, and the oxygen concentrator was observed to still be set at 2 LPM. The black oxygen cabinet filter located on the left side of the oxygen concentrator as the day before was still dirty and full of white lint. When R62 was asked if they had ever seen staff change out or clean the filter on the oxygen concentrator, R62 stated, No, I don't think so. On 04/08/2026 at 12:35 PM, Licensed Practical Nurse (LPN) 1 was shown R62's oxygen concentrator and dirty filter located on the side. LPN 1 took the black filter off the oxygen concentrator and confirmed the filter was very dirty with a heavy buildup of white lint and stated that she was not aware of when the filter was last cleaned. I can see it needs to be cleaned, and we will get it done. On 04/08/26 at 3:51 PM, during a review of the Oxygen Concentrator Testing log the Maintenance Director (MD) MD stated, With the oxygen concentrator filters, they should be changed every thirty days. We can take them out, blow them off, rinse them, dry them then put them back. Nursing or the CNAs [Certified Nurse Aides] are supposed to change out the filters at least every thirty days. When asked if aware of R62's oxygen concentrator filter being cleaned, the MD stated, I'm not aware of the filter not being changed out. The MD then stated, It would be my expectation that the day shift nursing and/or CNAs are checking those on the day shift preferably. The MD reviewed an Oxygen Concentrator Testing document which revealed the purchase date for the oxygen concentrator was 04/2024. It further revealed on 01/26/2026 the Filter was clean and changed on 01/26/2026 and was good. The MD stated, It was last tested on [DATE] and that would have been the last time it was cleaned. After that, it would have been in the supply room, and I don't know when it would have made it to the resident to be used. I don't have a record of that. I can see, though, the last time the filter was clean or changed out would have been on 01/26/2026, and I don't have a record if it had been changed out since then. R5 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), and chronic cough. R5's Physician Orders revealed, Oxygen: Oxygen at 2L/min per NC. May titrate to keep O2 (oxygen) sats (saturations) > (greater than) 92% as needed for SOB related to Chronic Obstructive Pulmonary Disease. On 04/07/2026 at 2:10 PM, R5 was observed wearing oxygen via nasal cannula. The oxygen tubing was connected to the oxygen concentrator which was set at 2 LPM. The black oxygen cabinet filter located on the left side of the concentrator was observed to be very dirty and full of a thick buildup of white lint. On 04/08/2026 at 8:55 AM, the same black oxygen cabinet filter located on the left side of the oxygen concentrator as the day before was still dirty and full of white lint. On 04/08/2026 at 10:15 AM, R5 was on Oxygen set a 2 LPM. The same black oxygen cabinet filter located on the left side of the oxygen concentrator as the day before was still dirty and full of white lint. On 04/08/26 at 11:30 AM, R5 was awake and watching television. R5 was observed with the oxygen on and set at 2 LPM. The filter was still observed to be dirty and full of white lint. R5 was asked if they had ever seen staff change out or clean the filter on the oxygen concentrator, R5 stated, No, I don't think so. On 04/08/2026 at 12:15 PM, LPN1 stated, We are supposed to be cleaning the filters. Any of the night nurses can change the filters on the concentrators if they are dirty. Usually that would be the nursing staff doing that. They can easily be cleaned with water and replaced. On 04/08/2026 at 12:30 PM, LPN 1 was shown R5's oxygen concentrator and filter located on the side. When LPN 1 took off the black filter from the concentrator, the filter was now observed to be clean. LPN1 stated, I just changed it out today because I saw it needed to be cleaned. It was around 12:25 PM, and I replaced it. LPN1 then stated, I saw it was very dirty and had not been changed. During an interview and review of the Oxygen Concentrator Testing log for R5 with the MD On 04/08/2026 at 3:51 PM, during review of the Oxygen Concentrator Testing log for R5, the MD stated, Someone had brought it to my attention today that the concentrator filter was dirty and had not been changed out. I was not aware of that prior to today, and nobody had brought anything to my attention. When reviewing the Oxygen Concentrator Testing log, it revealed the concentrator was purchased on 02/13/2026, and the Filter Clean/Change Date was listed as 02/16/2026. The MD stated, This was a new concentrator that came in on 02/16/2026 and would have sat in our supply room. I'm not sure when it would have gone out to the resident. I don't have a record of that. The MD further stated, I don't have an additional log or documentation of when the filter was cleaned or changed out after 02/16/2026. R79's was admitted on [DATE] with medical diagnoses including COPD with exacerbation, acute respiratory failure with hypoxia and hypercapnia, pulmonary hypertension due to lung disease with hypoxia, and heart failure. On 04/07/26 at 11:49 AM, R79 was observed to be seated in a wheelchair receiving oxygen via nasal canula at 3 LPM, confirmed by R79. Observation of the exterior intake filter of the oxygen concentrator noted a significant buildup of dust/lint. R79 stated they had been at the facility approximately one month. On 04/08/26 at 10:23 AM an observation of the concentrator's exterior filter revealed no changes in the filter status. Registered Nurse (RN) 3 observed the filter on 04/08/26 at 10:35 AM and stated, Oh, that's dirty. RN3 confirmed the filter needed cleaning. On 04/08/2026 3:53 PM, the MD stated concentrators were sent back to their office monthly by hall. The first week of the month the 100 hall was done; second week, 200 hall, third week 300 hall, and the fourth week of the month was the 400 hall. Filters were blown out when the concentrator was reviewed. The MD stated the concentrator for R79 was last serviced on 03/09/2026 and went into service on 03/12/2026. When asked if it was serviced the fourth week of March, the MD stated, No, it hadn't been 30 days. When asked to clarify if servicing was done by week and hall or based on date of issuance, the MD confirmed the concentrator was not serviced the fourth week of March and would not have been done until the fourth week of April. On 04/10/2026 at 2:00 PM, the Regional [NAME] President of Operations stated there were no other policies regarding cleaning. The facility's policy titled, Oxygen Administration, implemented 04/11/2025, revealed: 7. Cleaning and care of equipment shall be in accordance with facility policies for such equipment.

Based on observation, interview, and facility policy review, the facility failed to ensure that laundry staff were aware of what Personal Protective Equipment (PPE) was available for staff to use while sorting dirty laundry. This deficient practice had the potential to spread infectious organisms throughout the facility of 90 residents.Findings include:On 04/10/2026 at 4:00 PM, during an observation of the laundry area, no face shields or goggles were observed anywhere in the vicinity of the sorting area.On 04/10/2026 at 4:01 PM, a laundry aide was asked about PPE in the dirty area where clothes were separated for washing. The laundry aide stated the clothes were brought in the barrel, taken from it, and placed into whites or colored for wash. The laundry aide was asked if aprons, gloves, and eye protection were available and where they were located. The laundry aide stated she had an apron, but it was at home. When asked about gloves and eye protection, the laundry aide stated they wore their reading glasses. During an interview on 04/10/26 at 4:15 PM, the Director of Nursing (DON) was asked to come back to the laundry area. The laundry aide was asked about wearing PPE for sorting laundry. The laundry aide stated they had an apron, but it was at home. The DON asked why it was at home. The laundry aide stated they forgot it when taking it home to wash it. When asked about gloves and eye protection the laundry aide stated the gloves were on the wall. The laundry aide did not know where the eye protection was and never had. The DON stated, I will get you a face shield.On 04/10/2026 at 4:25 PM, the DON was asked what the expectations were for sorting laundry. The DON stated the expectation was not to take aprons home and that there be face shields for eye protection available. The facility's policy titled, Infection Prevention and Control Program, implemented on 04/11/2025, revealed, Policy: This 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 . 12. Linens: a. Laundry and direct and direct care staff shall handle, store, process, and transport linens to prevent spread of infection .

Based on interview, record review, and document review the facility failed to ensure a resident was free from neglect for an unsampled resident (Resident 182). The deficient practice resulted in a superficial burn injury. Findings include: Resident 182 (R182) was admitted on [DATE] with diagnoses including fracture of shaft of left femur and abnormalities of gait and mobility. The facility reported to the state agency a Certified Nursing Assistant (CNA) had reported R182 was having back pain on 12/26/2024 at 5:00 PM. The CNA notified the nurse and Director of Nursing (DON). R182 was assessed and an abrasion with redness on the mid back area was identified. R182 reported having a heating pad on earlier in the day while in therapy. The Therapist confirmed the heating pad was applied to R182's lower back during therapy with two layers of protection. The resident complained the heat was too warm and the therapist added two more layers of protection. The resident confirmed it was a comfortable temperature and helping with back pain. The medical record indicated R182 had curvature of the spine and was known to have movement in bed and probable cause for wound was shearing. On 12/26/2024 the facility notified the wound specialist and wound nurse of abrasion on R182's back and received orders for wound care. On 12/28/2024 the DON reassessed the wound and noted wound condition had deteriorated. The DON notified the wound specialist of change in wound condition as well as the Nurse Practitioner, family, and Administrator. On 12/30/2024 the wound specialist assessed the wound and indicated the wound appeared more consistent with a burn versus an abrasion from shearing. On 12/30/2024 the facility initiated a self-report to the state agency based on report from wound specialist describing wound as potentially from a burn. On 12/30/2024 the wound specialist conducted an assessment and found R182 had pain at site only when touched, wound had redness on the skin with superficial open wound. No burning around wound was noted, behavior of R182 did not change and resident indicated wound was not interfering with daily activities. The facility initiated an internal investigation and identified and suspended the staff member involved in placing moist heat pad on resident. The staff member was identified as Occupational Therapy Assistant. On 05/01/2025 at 10:25 AM, the Director of Rehabilitation (DOR) identified the Certified Occupational Therapy Assistant (COTA, E1) as having placed moist heat on the back of R182. The DOR indicated the heat pad would automatically have four layers of protection and based on the statement from E1 an additional two to four layers of protection were placed for comfort. During the internal investigation it was found E1 had left the heat in place and did not supervise the resident as required. E1 notified a CNA where the resident was however E1 moved on to other tasks leaving the resident unsupervised while resident was sleeping with heat pack in place. The amount of time was unknown however E1 did not return to check on resident for more than 20 minutes. The DOR indicated the actions of E1 were improper and against facility policy as the CNA was not educated in supervision of residents being treated with moist heat. A facility policy and procedure titled Moist Heat Packs documented to check on resident every five to ten minutes and treatment should not exceed twenty minutes while having moist heat in place. On 05/01/2025 at 10:30 AM, the Abuse Coordinator indicated the facility initiated an investigation as soon as information was obtained which indicated the resident suffered a burn injury. During the investigation it was discovered the staff member failed to follow proper heating modality protocols and was determined to be the likely cause of the skin impairment. After completing the investigation, the facility determined neglect had occurred and immediately terminated E1. Following termination of E1 additional corrective measures were taken: - all therapist checklists were verified and updated. - moist heat therapy was discontinued at the facility. - all therapy staff received in-service on heat modalities. On 01/07/2025 all interventions for correction of deficient practice had been implemented by the facility. The facility policy titled Abuse (revised June 2024) documented every resident had the right to be free from all forms of abuse and neglect. Neglect was defined as the failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. FRI NV00073064

Based on observation, interview, record review and document review, the facility failed to ensure a resident who was observed taking own medications was assessed for capability to self-administer medications for 1 of 18 sampled residents (Resident 54). The deficient practice had the potential to compromise the resident's safety and negatively impact overall well-being. Findings include: Resident 54 (R54) was admitted on [DATE] and readmitted on [DATE], with diagnoses including Parkinsonism, bipolar disorder and post-traumatic stress disorder. On 04/29/2025 at 12:25 PM, R54 was seated in room with lunch tray in front, a small cup containing multiple medications was observed on the meal tray. R54's hands tremors were evident as R54 placed the medications on top of the yogurt container and started to consume the medications and yogurt using an adaptive spoon. During the consumption, a small portion of a pink pill fell on the resident's blouse. R54 explained the medications were routine medications scheduled with the lunch meal and was left by the nurse for the resident to take. There were no staff members inside the resident's room during the observation. On 04/29/2025 at 12:30 PM, a Licensed Practical Nurse (LPN) indicated being assigned to R54 and acknowledged leaving six medication pills on R54's meal tray namely: 1) Prazosin (antihypertensive), 2) Gabapentin (anticonvulsant), 3) Cyclobenzaprine (muscle relaxant), 4) Carbidopa-Levidopa (Dopamine agonist for Parkinson's disease), 5) Mirapex (Dopamine agonist for Parkinson's disease) and 6) Percocet (opioid for pain). The LPN indicated R54 could be trusted to take own medications, so the nurse thought it was okay to leave the medications with the resident. The LPN confirmed the medications had been documented as administered without direct observation of R54's consumption of the medications by the nurse. On 04/29/2025 at 12:35 PM, the LPN confirmed R54 did not have an assessment for self-administration of medications. On 04/30/2025 at 9:34 AM, the Director of Nursing (DON) indicated an assessment for self-administration of medications was required for residents who expressed a desire to take own medications. The DON indicated the assessment ensured the resident could safely administer own medications and required a physician's approval. The DON confirmed R54 did not have an assessment for self-administration of medications but even if an assessment was in place, it would still not be right for the nurse to document the medications as administered without direct observation of the consumption of medications. The Self Administration of Medications policy revised December 2012 documented if a resident expressed the desire to self-administer medications, the staff and provider would assess the resident's mental and physical abilities to determine whether a resident was capable of self-administering medications. The Medication Storage policy dated 04/11/2025, documented during a medication pass, medications must be under the direct observation of the person administering the medications.

Based on observation, interview, record review and document review, the facility failed to ensure consents for psychotropic medications were not obtained from a resident who was assessed to have severely impaired cognition for 1 of 18 sampled residents (Resident 36). The deficient practice potentially deprived the resident and the resident's representative the right to be informed of the medications' purpose, risks, benefits and potential side effects. Findings include: Resident 36 (R36) was admitted on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, bipolar disorder and anxiety disorder. The Annual Minimum Data Set (MDS) dated [DATE], documented R36 had a brief interview of mental status (BIMS) score of 03 (severely impaired cognition). 1) A Physician's Order dated 04/01/2024, documented to give Trazadone (anti-depressant) 150 milligrams (mg) by mouth at bedtime for sleep disorder. A Consent for Psychotropic Medication Use dated 04/02/2024, revealed the Assistant Director of Nursing (ADON) completed the consent form for Trazadone and the risk, benefits, potential side effects of the medication were discussed with R36. The document had the physical signatures of the ADON and R36. 2) A Physician's Order dated 11/15/2024, documented to give Latuda (anti-psychotic) 20 mg by mouth one time a day for bipolar disorder. A Consent for Psychotropic Medication Use dated 11/15/2024, revealed the behavioral specialist nurse completed the consent form for Latuda and the risk, benefits, potential side effects of the medication were discussed with R36. The document had the physical signatures of the behavioral specialist nurse and R36. 3) A Physician's Order dated 07/01/2024, documented to give Buspirone (anti-anxiety) 5 mg by mouth three times a day for generalized anxiety disorder. A Consent for Psychotropic Medication Use dated 07/01/2024, revealed the Assistant Director of Nursing (ADON) completed the consent form for Buspirone and the risk, benefits, potential side effects of the medication were discussed with R36. The document had the physical signatures of the ADON and R36. On 05/01/2025, R36 was seated in the activity room inside the 100-Hall memory unit. The DON showed R36 the consent forms for Trazadone, Latuda and Buspirone and R36 confirmed the signatures on the consent forms were of R36's. R36 was observed telling the DON being familiar with the medications Trazadone and Latuda but expressed not knowing what Buspirone was and for what purpose the resident was taking the medication. On 05/01/2025 at 4:12 PM, the ADON confirmed completing R36's consent forms for Trazadone and Buspirone and indicated the consent form for Latuda was completed by the behavioral specialist nurse. The ADON recalled discussing the medications with R36 because the family member who used to be involved in R36's care had passed away. On 05/01/2025 at 4:14 PM, the Director of Nursing (DON) indicated a BIMS score of 03 reflected R36 had severely impaired cognition and the resident did not have the mental capacity to sign psychotropic consent forms. The DON indicated being aware R36 had a family member who passed away, but another family member was appointed as R36's power of attorney (POA) or responsible party. The DON indicated the nurses should have obtained informed consent from R36's responsible party and not from the resident who had a diagnosis of dementia with severely impaired cognition. The Use of Psychotropic Medications policy dated 04/11/2025, documented prior to initiating a psychotropic medication, the resident, family or resident representative must be informed of the benefits, risks, and alternatives for the medication.

Based on observation, interview, record review and document review, the facility failed to ensure a nurse did not document medications as having been administered without direct observation of the resident's consumption of the medications for 1 of 18 sampled residents (Resident 54). The deficient practice had the potential to compromise the resident's safety and inaccurately document care provided to the resident. Findings include: The Medication Administration policy dated 04/11/2025, documented medications were administered by licensed nurses as ordered by the physician in accordance with professional standards of practice. Nurses would administer medications and observe resident consumption of medication. Resident 54 (R54) was admitted on [DATE] and readmitted on [DATE], with diagnoses including Parkinsonism, bipolar disorder and post-traumatic stress disorder. On 04/29/2025 at 12:25 PM, R54 was seated in room with lunch tray in front, a small cup containing multiple medications was observed on the meal tray. R54's hands tremors were evident as R54 placed the medications on top of the yogurt container and started to consume the medications and yogurt using an adaptive spoon. During the consumption, a small portion of a pink pill fell on the resident's blouse. R54 explained the medications were routine medications scheduled with the lunch meal and was left there by the nurse for the resident to take. There were no staff members inside the resident's room during the observation. On 04/29/2025 at 12:30 PM, a Licensed Practical Nurse (LPN) indicated being assigned to R54 and acknowledged leaving six medication pills on R54's meal tray namely: 1) Prazosin (antihypertensive), 2) Gabapentin (anticonvulsant), 3) Cyclobenzaprine (muscle relaxant), 4) Carbidopa-Levidopa (Dopamine agonist for Parkinson's disease), 5) Mirapex (Dopamine agonist for Parkinson's disease) and 6) Percocet (opioid for pain). The LPN indicated R54 could be trusted to take own medications, so the nurse thought it was okay to leave the medications with the resident. The LPN confirmed the medications had been documented as administered without direct observation of R54's consumption of the medications by the nurse. On 04/30/2025 at 9:34 AM, the Director of Nursing (DON) indicated the facility utilized the [NAME] professional standard of nursing practice. The DON stated the six rights of medication administration included right resident, right drug, right dosage, right route, right time and right documentation. The DON acknowledged the nurse assigned to R54 did not follow the standard of practice for medication administration when the nurse left the medications for the resident to take by themselves and proceeded to document the medications as administered without direct observation of consumption of the medications. The Lippincott Nursing Practice 11th edition, revealed common departures from standards of nursing care included failure to adhere to the facility's policies and procedures, follow appropriate nursing measures, and document accurate information in the resident's medical record. The resident's response to nursing interventions must be recorded precisely and concisely.

Based on observation, interview and document review, the facility failed to ensure the medication storage room was free from expired medications. The deficient practice placed residents at risk for receiving expired medications. Findings include: On 04/30/2025 at 9:04 AM, a Licensed Practical Nurse (LPN) indicated the facility had one medication storage room. An inspection of the over-the-counter (OTC) medication cabinet was conducted with the LPN who confirmed the following observation: - seven bottles of Fexofenadine hydrochloride 30 tablets per bottle. Lot number AT2301068 expiration date January 2025 - four bottles of Calcium citrate 100 enteric-coated tablets per bottle. Lot number 254715 expiration date December 2024 - three bottles of Dehydroepiandrosterone (DHEA) micronized dietary supplement 24 tablets per bottle. Lot 112107 expiration date November 2024 - three bottles of Calcium Oyster shell 500mg plus Vitamin D3 60 chewable tablets per bottle. Lot 62300 expiration November 2024 - three bottles of saline enema Lot 2301 expiration August 2024 On 04/30/2025 at 9:22 AM, the LPN indicated the medication storage room should not contain any expired medications. The LPN indicated not being aware who was responsible for checking the medication room and how often this should be done. The LPN deferred to the Director of Nursing (DON) for the facility process regarding the medication storage room. On 04/30/2025 at 9:27 AM, the DON indicated the medication storage room should be inspected at least once a month and central supply who stocked the OTC cabinet was responsible for ensuring expired medications were removed from the medication room. The DON verbalized the medication storage room must not contain any expired medications in accordance with facility policy. The DON acknowledged the findings reflected a lack of clear process on maintenance of the medication room. The Medication Storage policy dated 04/11/2025, documented the medication room were to be routinely inspected by the consultant pharmacist or designee for discontinued, outdated and deteriorated medications.

Based on observation, interview, and document review, the facility failed to ensure stored foods were stored in accordance with facility standards for food service safety and sanitization test strips to measure correct sanitizing levels were not expired. These deficient practices posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness. Findings include: On [DATE] in the morning, during a tour of the kitchen and dietary areas, an open undated drink bottle was found in the 400-hall nutrition refrigerator. A pre-dispensed, unlabeled, and undated bowl of cereal was stored in the 300-hall nutrition cabinet. An expired (,d+[DATE]) can of cocoa powder was being stored in the 100-hall nourishment cabinet. A facility policy entitled Date Marking for Food Safety implemented on [DATE], revealed food would be clearly marked to indicate the date or day by which the food would be consumed or discarded. The individual who opened or prepared a food would date mark the food at the time the food was opened or prepared. The marking system would consist of the day/date of opening and the day/date the item must be consumed or discarded. The discard day or date would not exceed the manufacturer's use-by date, whichever is earliest. Food items that were expiring, would be discarded accordingly. The Dietary Manager verified the undated drink bottle in the 400-hall nutrition refrigerator should have been dated at the time the bottle was opened and clearly marked to indicate the date or day by which the food would be consumed or discarded. The Dietary Manager verified a pre-dispensed, unlabeled, and undated bowl of cereal which was stored in the 300-hall nutrition cabinet should have been labeled as to the contents in the bowl, date marked the food at the time the food was prepared, and date marked the day/date the item must be consumed or discarded. The Dietary Manager verified the can of cocoa powder which was being stored in the 100-hall nourishment cabinet which had expired on ,d+[DATE], should have been discarded accordingly. On [DATE] in the morning, during a tour of the kitchen, there were sanitizing test strips above the three-compartment sink which had expired ,d+[DATE]. The facility did not have any replacement sanitizing test strips available. A facility policy entitled Dietary Sanitization revised [DATE], revealed manual washing and sanitizing of food preparation equipment and utensils will employ a three-step process for washing, rinsing and sanitizing. When sanitizing with chemical solutions, the chemicals must consist of either Chlorine 50 ppm, Iodine 12.5 ppm, or quaternary ammonium compound ,d+[DATE] ppm. The Dietary Manager acknowledged the sanitizing test strips above the three-compartment sink were expired. The Dietary Manager explained the supply company had sent the facility expired test strips and therefore the facility did not have any non-expired test strips. The Dietary Manager acknowledged the kitchen staff was not able to accurately measure if the sanitizing solution in the three-compartment sink was at the appropriate levels.

Based on interview, record review and document review, the facility failed to ensure a resident's blood pressure and heart rate were obtained and parameters were followed in accordance with physician's order for an anti-hypertensive medication for 1 of 18 sampled residents (Resident 36). The deficient practice resulted in unnecessary medications. Findings include: Resident 36 (R36) was admitted on [DATE] and readmitted on [DATE], with diagnoses including essential hypertension (high blood pressure). A physician's order dated 12/05/2024, documented Losartan Potassium 25 milligrams (mg) give half tablet by mouth once daily for essential hypertension. Hold for systolic blood pressure (SBP) less than 100 millimeters of Mercury (mmHg) and heart rate (HR) less than 55 beats per minute (bpm). The medical record lacked documented evidence R36's BP and HR were obtained and recorded in the resident's electronic health record (EHR) to reflect BP and HR parameters were being followed per physician's order. On 05/02/2025 at 9:15 AM, the Assistant Director of Nursing (ADON) explained the physician's order specified BP and HR parameters to follow for the administration of R36's Losartan. The ADON confirmed R36's Losartan was administered daily from 04/01/2025 to 04/30/2025 without a single recorded BP or HR. The ADON explained the facility transitioned to another EHR software in April 2024 and nurses were trained on how to enter vital signs such as BP, HR, pain level, and blood sugar, which were expected to be recorded in the residents' medication administration record (MAR) whenever a medication order came with parameters to follow. The ADON acknowledged physician's orders were not followed when Losartan was administered to R36 on a routine basis without recorded BP and HR. On 05/02/2025 at 9:59 AM, the Director of Nursing (DON) explained certified nursing assistants (CNAs) were responsible for obtaining vital signs on all residents at least once per shift. The CNAs would submit a vital signs sheet to the medication nurses who were expected to record the vital signs in the resident's MAR whenever medication orders came with parameters to follow. The DON confirmed R36's BP and HR were not recorded in the MAR and BP readings were found in another place of the resident's medical record on 04/04/2025, 04/11/2025 and 04/18/2025. The DON verbalized the facility followed a not documented not done standard of practice and acknowledged there was no documented proof R36's Losartan was administered as ordered in the absence of BP and HR readings. The Unnecessary Drugs policy dated 04/11/2025, revealed each resident's drug regimen was managed and monitored to promote and maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. The attending physician will assume leadership in medication management and each resident's drug regimen would be reviewed on an ongoing basis taking into consideration indications and clinical need, adequate monitoring and efficacy. Documentation would be provided in the resident's medical record to show adequate indications for the medications use and diagnosed condition for which it was prescribed.

Based on observation, interview, record review, and policy review, the facility failed to have menu spreadsheets for the weekly menus that included portion sizes and regular and therapeutic diets for all residents and three of eight residents R16, R29, and R34) who were reviewed for menus. This deficient practice affected all residents who received meals prepared in the facility's only kitchen. Findings include: Review of the facility policy titled Menu Planning, revised 09/10, revealed: Purpose: To provide a variety of meals that are well balanced, palatable, attractive, satisfying and meet the recommended daily allowances. 2. Menus will be developed by following resident's food preference and by maintaining state and federal standards. Review of the facility diet roster, dated 04/24/24, provided by the facility revealed diet orders included 45 regular diets, nine mechanical soft diets, two pureed diets, one pureed high calorie high protein diet, four mechanical soft high calorie high protein diets, 12 regular high calorie high protein diets, and two regular high protein diets. Review of the facility's weekly menus, dated 03/31/24 through 04/27/24, provided by the facility, revealed no portion sizes or therapeutic extensions. Review of the facility assessment, dated 2024, provided by the facility revealed under section D.2. Cultural - Food & Nutrition revealed the diets the facility provided included Vegetarian, Vegan, Kosher, Sugar-free, Caffeine-free, Organic, Dairy, Dairy substitutes (e.g. soy), Gluten-free, Protein preferences (e.g. beef, pork, fowl, fish, vegetarian), and other diet. On 04/22/24 at 12:22 PM, meal service was observed in progress in the satellite kitchen on the 300 hall. Cook1 used a 13-inch serving spoon and a 6-ounce spoodle spoon to portion the food. The Tray line included regular textured chicken, cheese ravioli, sweet potatoes, cake, and four-ounce dishes of tossed salads. No menu spreadsheets were observed. Cook1 confirmed the food on the tray line was all the foods for lunch. On 04/23/24 at 7:48 AM, Cook1 was observed serving breakfast in the satellite kitchen on the 300 hall. Cook1 used a 6-ounce spoodle spoon, 13-inch serving spoon, and a 2.7-ounce scoop to portion the scrambled eggs. No menu spreadsheets were observed. Cook1 confirmed the food on the tray line was all the foods for breakfast. On 04/23/24 at 12:20 PM, Cook1 was observed serving lunch in the satellite kitchen on the 200 hall using a 6-ounce spoodle spoon, 13-inch serving spoon, tongs, and a four-ounce scoop. Cook1 was asked how the employee knew what serving utensil to use. Cook1 stated knew from what the employee had always done. Cook1 was asked if had menus to serve from for serving sizes and Cook1 stated, no. The tray line included rice, meatballs in white gravy, regular textured pork roast, butternut squash, and mechanical soft meatballs. The puree food was already portioned on a plate and the ambrosia salad was already portioned in four-ounce bowls. Cook1 confirmed the food on the tray line was all the foods for lunch. During an interview on 04/23/24 at 12:30 PM, the Food Service Manager (FSM) was asked for the spreadsheets for this week's menus. The FSM stated there were no spreadsheets for this week's menus as the facility was transitioning to a new company with new menus. On 04/24/24 at 12:14 PM, Dietary Aide (DA)2 was observed serving lunch in the satellite kitchen on the 300 hall. DA2 used a six-ounce spoodle spoon, 13-inch serving spoon, and a four-ounce scoop and no menu to follow. The tray line included regular textured salisbury steak patty, cod fish, mashed potatoes with gravy, bread, strawberry shortcake, four-ounce bowls of fruit and four-ounce bowls of tossed salad already dished up when the food arrived to the unit. On 04/23/24 at 3:47 PM, the FSM was asked about serving portions and menu spreadsheets. The FSM confirmed staff were not using the menus to work off of as there were no spreadsheets. The FSM stated the staff were using what they have always done before the FSM had started employment at the facility. On 04/24/24 at 8:12 AM, Cook1 was asked about the serving utensils. Cook1 pointed to a posting in the kitchen for portion sizes and confirmed did not have menus to use for serving sizes. On 04/25/24 at 7:41 AM, the FSM was asked about recipes for the menus. The FSM stated they don't have recipes for everything, there were several binders in various locations, and so will look some recipes up online. The FSM went on to say wasn't trained on the current menu program and was still learning the process. The FSM confirmed the staff weren't working from menu spreadsheets with portion sizes, saying just using the portion size guide posted in the kitchen. During a telephone interview on 04/25/24 at 9:44 AM, the Registered Dietitian (RD) was asked if was aware the kitchen had no menu spreadsheets for therapeutic diets and serving sizes to work from. The RD stated, no, wasn't aware. The RD stated the regular RD was on leave and was just helping out. Resident 29 (R29) Review of R29's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/24, revealed R29 had an admitted [DATE]. R26 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating R29 had moderately impaired cognition, diagnoses of Alzheimer's disease, respiratory failure, and dysphagia, and was on a mechanically altered diet. Review of R29's diet order, dated 09/16/22, revealed order for Regular High Calorie/High Protein. Texture: Mechanical Soft. R29's nutrition assessment, dated 02/26/24, revealed . Diet: high cal[calories]/high pro [protein] dysphagia mechanical soft diet with a reported PO [oral] intake of 50-75% which is likely adequate to meet nutrition needs but noted recent admission to the hospital and some 1-25% PO intake days since readmission; will continue to monitor with weekly weights until stable . R29's care plan, revised 03/15/24, documented, Problem: R29 is at risk for altered nutrition. Albumin on 10/19/23 is 3.5 slightly under ideal range. BMI [body mass index] is within ideal BMI at 22.92 on 11/04/23. [R29] is losing weight, in 90 days on 11/04/23 the resident triggered for 5.1% weight loss in 90 days. An approach included RD recommended to continue with High Calorie High Protein diet for now. If weight gain continues above IBW [ideal body weight] range, it may be appropriate to change diet to Regular. On 04/22/24 at 12:30 PM, R29 was observed in a wheelchair seated at a dining room table. R29 was served chicken, sweet potatoes, mixed vegetables, cake, bread, coffee, and a glass of milk. The 04/22/24 lunch menu, provided by the facility revealed chicken thighs, sweet potatoes/brussels, bread sticks, hurricane cake or cheese ravioli, tossed salad, bread sticks, and hurricane cake. No serving sizes or a diet for a Regular High Calorie/High Protein. Texture: Mechanical Soft was listed. On 04/23/24 at 7:46 AM, R29 was observed in a wheelchair seated at a dining room table. R29 was served scrambled eggs, a two-ounce portion of fruit, a sausage patty, a danish, and a glass of milk. The 04/23/24 breakfast menu, provided by the facility revealed danish, cream of wheat or cold cereal, scrambled eggs, bacon, toast, and fruit/yogurt. No serving sizes or a diet for a Regular High Calorie/High Protein. Texture: Mechanical Soft was listed. On 04/23/24 at 12:43 PM, R29 was observed in a wheelchair seated at a dining room table. R29 was served coffee, rice, swedish meat balls, a roll, butternut squash, ambrosia dessert, and a glass of milk. The 04/23/24 lunch menu, provided by the facility revealed swedish meatballs, white rice, steamed veggies, and ambrosia or pork chops, cheesy potatoes, baked beans, biscuit, and ambrosia. No serving sizes or a diet for a Regular High Calorie/High Protein. Texture: Mechanical Soft was listed. On 04/24/24 at 1:55 PM, the FSM was asked if there were menus for R29's mechanical soft high calories and protein diet. The FSM responded no. The FSM asked why R29 was on a high calorie high protein diet. The FSM states didn't know why but maybe needed it for weight. The FSM was asked if it could be due to a low albumin (protein made by the liver) per the care plan. The FSM stated didn't know what albumin was as is still learning. The FSM was asked how the high calories/high protein portion of the resident's meal was being accomplished as the resident had received the same meals as other residents on 04/22/24 at lunch and on 04/23/24 at breakfast and lunch. The FSM stated they sometimes fortified with extra butter and calories. The FSM was asked why was R29's diet dished up from the same pans as the other residents with nothing extra added on 04/22/24 at lunch and on 04/23/24 at breakfast and lunch. The FSM stated wasn't sure as still learning the job. The FSM stated their diet manual didn't include a high calorie high protein diet. During a telephone interview on 04/25/24 at 9:44 AM, the RD was asked about R29's prescribed diet of high calories and protein but the resident had received a regular diet on 04/22/24 at lunch and on 04/23/24 at breakfast and lunch. The RD stated they have a policy for power foods that could have been added to the residents' meals for high calorie and protein. The RD stated was not aware the policy wasn't being utilized. Resident 16 (R16) Review of R16's significant change MDS with an ARD of 02/09/24, revealed R16 had a admitted [DATE]. R16 had a BIMS score of 11 out of 15, indicating R16 had moderately impaired cognition and diagnoses included cerebral infraction, aphasic, dementia, Parkinson's disease, dysphagia, received hospice care, and was on a mechanically altered diet. Review of R16's diet order, dated 05/03/22, revealed Regular. Texture: Puree. R16's care plan, dated 10/18/23, revealed R16 is at risk for altered nutritional status related to dysphagia with puree diet and underlying dementia. The approach included Regular, Puree Texture Diet with assistance. R16's nutrition assessment, dated 02/09/24, documented: .Diet: regular pureed diet with reported PO intake of 50% or more of meals when resident is fed . On 04/23/24 at 7:53 AM, R16 was served breakfast in bed. R16 was observed to have three beverages in sippy cups, two servings of apple sauce, one yogurt, and two mugs filled with oatmeal on the overbed table. Nurse aide in training (NAT)2 was at the bedside mixing milk in the oatmeal turning it into a liquid. NAT2 confirmed this was R16's standard breakfast. The 04/23/24 breakfast menu, provided by the facility revealed danish, cream of wheat or cold cereal, scrambled eggs, bacon, toast, and fruit/yogurt. No serving sizes or a diet for a Regular. Texture: Puree was listed. On 04/23/24 at 12:41 PM, R16's lunch included a bowl of broth, puree mashed potatoes, puree mixed vegetables, and puree ambrosia. The 04/23/24 lunch menu, provided by the facility revealed swedish meatballs, white rice, steamed veggies, and ambrosia or pork chops, cheesy potatoes, baked beans, biscuit, and ambrosia. No serving sizes or a diet for a Regular. Texture: Puree was listed. On 04/24/24 at 12:40 PM, R16's lunch included puree meat, puree mashed potatoes, puree carrots and green beans, yogurt, and puree strawberry shortcake. The 04/24/24 lunch menu, provided by the facility revealed chicken [NAME], bow tie pasta, spinach salad, bread sticks, strawberry shortcake or baked cod, savory rice, spinach salad, bread stick, and strawberry shortcake. No serving sizes or a diet for a Regular. Texture: Puree was listed. On 04/23/24 at 12:30 PM, The FSM was asked about R16's sippy cup and the caregiver adding milk to the resident's oatmeal. The FSM stated this is the way it was done when the FSM had started employment in 12/12/23. The FSM was asked about puree diets. The FSM stated had three pureed diets in the facility, R16 was one of them, and the puree foods should mirror the regular meal as much as possible. The FSM was asked if there were no menus to follow for puree, how did the staff know what will puree. The FSM stated instructs Cook1 to make the decision as to what the meal should be, based on the same foods as the regular diets and what purees the best. The FSM was asked how could ensure R16's puree diet wasn't given the same foods too much and the diet was balanced if the staff were deciding on the puree foods. The FSM stated the Registered Dietitian (RD) reviewed the menu changes. The FSM then provided a menu with handwritten changes marked and there was no mention of pureed foods. During a telephone interview on 04/25/24 at 9:44 AM, the RD was asked about R16's prescribed puree diet and the caregiver adding/preparing the resident's breakfast at bedside, making it into a liquid consistency and no spreadsheet to follow. The RD stated wasn't aware this was occurring. Resident 34 (R34) Review of R34's significant change MDS with an ARD of 01/09/24, revealed R34 had an admitted [DATE]. R16 had a BIMS score of 13 out of 15, indicating R34's cognition was intact and had a diagnosis of diabetes mellitus with diabetic neuropathy. Review of R34's diet order, dated 09/25/20, revealed Regular Diet/Regular Texture. Review of R34's care plan, dated 04/16/24, revealed Problem: R34 is at a potential nutritional risk due to poor diet choices and diagnosis of diabetes. An approach included ST [speech therapy] recommended mechanical soft. R34 signed a waiver to allow regular texture. Currently, Diet: Regular Diet/Regular Texture. Vegetarian preferences. Review of R34's nutrition assessment, dated 04/08/24, documented: .Diet Regular, Regular Texture- prefers limited concentrated sweets and vegetarian. Meds [medications]/supplement concentrated sweets and vegetarian . On 04/24/24 at 12:28 PM, R34 was served a meal that included rice, tossed salad, cake, and a roll. No meat or protein was provided at this meal. R34 was asked why the resident wasn't served an entree. R34 stated doesn't eat meat but would like to try vegetarian meat entrees. The 04/24/24 lunch menu, provided by the facility revealed chicken [NAME], bow tie pasta, spinach salad, bread sticks, strawberry shortcake or baked cod, savory rice, spinach salad, bread stick, and strawberry shortcake. No serving sizes or a diet for a Regular Diet/Regular Texture, and Vegetarian options was listed. On 04/24/24 at 12:51 PM, the FSM was asked about R34 not receiving a protein at lunch on 04/24/24 and wanting vegetarian options. The FSM stated R34 knew the facility didn't serve vegetarian diets prior to the resident's admission. The FSM stated had met with R34 multiple times asking what the resident would eat. The FSM stated the online diet manual they used didn't have vegetarian diets. On 04/25/24 at 9:44 AM, the RD was asked why R34 was not served a protein on 04/24/24 at lunch as the resident doesn't eat meat and there were no vegetarian menus included on the weekly menus to ensure R34's proteins needs were met. The RD stated their dietary program did offer vegetarian options. The RD stated wasn't aware the menus the facility was using didn't have serving sizes or therapeutic diets. The RD stated the FSM needed more training on how to access menu extensions.

Based on observation, interview and policy review, the facility failed to use proper procedures for handwashing, cooling leftovers, and dating leftovers. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. Findings include: Facility policy titled Use of Steam Table in Dining Area, dated 2020, revealed no instructions for holding temperature for hot and cold foods. Review of the United States Federal Food & Drug Food Code 2022: http://www.fda.gov/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/, revealed: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under . (C) of this section, time/temperature control for safety food shall be maintained: (1) At 57 [degrees]C [Celsius] (135 F[Fahrenheit]) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 C (41 F) or less. Facility's policy titled, Hand Washing Procedures, dated 08/19, revealed .3. Rinse hands, wrists and exposed forearms under clean, running warm water. 4. Apply soap to hands. 5. Vigorously lather all surfaces of hands with soap and rub together, creating friction to all Surfaces .8. Turn off faucets with a new clean, dry paper towel. (Do not use hand, back of hand or forearm to tum off faucet.) Facility policy's titled, Cooking and Cooling, dated 2020, revealed .3. Cooked foods that will not be served immediately must be held properly or cooled as quickly as possible according to the following guidelines: 4. Cool foods using a two-step process: 135 degrees F to 70 degrees F in the first two hours, and then 70 degrees F to 41 degrees F in the next four hours. Facility policy titled, Food Storage and Labeling Procedure, dated 09/22, revealed .2. Date: Document the date that the product is placed in the refrigerator. On 04/23/24 at 12:15 PM, Cook1 was observed taking the temperature of the food on the tray line in the satellite kitchen on the 200 hall just before meal service. Cook1 was asked what the temperature of the foods should be held at and Cook1 stated 165 degrees F. A plate of puree food already portioned was sitting on top of the steamtable lid. The puree mixed vegetables were measured at 98.9 degrees F, the puree pork measured at 120.2 F, the puree ambrosia dessert measured at 50 degrees F, and the regular ambrosia dessert measured at 49 degrees F. At 12:30 PM the Food Service Manager (FSM) was asked about the temperatures of the plated puree foods measuring below 135 degrees F and the ambrosia desserts measuring above 41 degrees F. The FSM stated the puree foods were prepared about 10:00 AM and held hot, but the staff should have microwaved the plate before it was served. On 04/23/24 at 3:00 PM, the FSM was asked if there were leftovers from lunch. The FSM stated yes, swedish meatballs and butternut squash. The FSM stated these items were placed in the refrigerator at 1:00 PM. A tall plastic container two thirds full of Swedish meatballs and a short, long plastic container completely full of butternut squash were observed in the reach-in refrigerator. Both containers were covered with cellophane wrap. The FSM was asked to take the temperature of the leftovers. The Swedish meatballs measured at 113 degrees F and the butternut squash measured at 89.6 degrees F. The FSM was asked if was aware of the requirement to cool hot foods to 70 degrees F within two hours, and if this was the correct method to cool leftovers. The FSM stated, no, wasn't aware of this requirement and the staff should have used a shallow pan, stirred it, or placed them in an ice bath. On 04/23/24 at 3:05 PM, a covered container of omelets was observed in the reach-in refrigerator with no date. The FSM was asked about the omelets and the FSM explained were left over from two days ago at breakfast on 04/21/24. The FSM confirmed the omelets should have been dated. On 04/23/24 at 2:46 PM, after the FSM was observed to wash hands in the hand sink located at the kitchen entrance, the FSM touched the faucet handles with bare hands while turning off the faucet. The FSM did not use a paper towel or a clean barrier to turn the faucet off. On 04/23/24 at 3:14 PM, Cook2 was observed to rinse hands with water and not use soap in between loading soiled dishes and then unloading clean dishes. Cook2 was asked if had used soap and replied, no. Cook2 then immediately stopped unloading the clean dishes and proceeded to wash hands properly with soap. The FSM was asked at this time what the proper procedures was for staff washing their hands. The FSM stated staff should wash their hands with soap before touching clean dishes.

Based on interview, record review and review of facility policy, the facility failed to ensure six residents (Residents (R) R40, R60, R5, R57, R19, and R130) were free from verbal and/or physical abuse. Specifically, the facility failed to ensure R40 and R60 were free from verbal abuse by an agency staff member, and R5, R57, R19 and R130 were free from resident-to resident physical abuse. These failures placed residents at risk for diminished quality of life. Findings include: Review of the facility policy titled, Definitions, dated 01/17 revealed, .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Verbal abuse means the use of oral, written or gestured language that includes disparaging and derogatory terms to a resident or their families within their hearing, regardless of their age, ability to comprehend or disability . 1. Verbal Abuse Resident 40 (R40) Review of the Admission Record revealed R40 was admitted to the facility on [DATE] with diagnoses including stroke with left-sided paralysis, bipolar disorder (a disorder associated with episode of mood swings ranging from depressive lows to manic highs), and affective mood disorder (marked disruptions in emotions). Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/26/24, revealed R40 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which indicated R40 was moderately impaired in cognition, had no behaviors, required partial assistance for transfers and did not ambulate. Resident 60 (R60) Review of the Admission Record revealed R60 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a neurological disease), bipolar disorder, and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of the quarterly MDS with an ARD of 12/27/23, revealed R60 had a BIMS score of 13, which indicated R60 was cognitively intact. Review of a 02/14/24 facility investigation report, provided by the Administrator documented, Reported by Registered Nurse (RN)1 that R60 was making an allegation of abuse towards Certified Nurse Assistant (CNA)1. Social Services Director (SSD) went to talk with R60 and reported R60 stated, I heard CNA1 tell R40 you are stupid, while assisting resident in the bathroom. This writer went to talk with R40 and when I asked resident if CNA1 had called R60 stupid, resident stated, yes, resident was asked if was ok, stated, yes, I am ok. I asked if anything else was said, resident stated no, the CNA just called me stupid. R40 did report that it made the resident feel sad. The facility investigation report further documented, At 15:45 (3:45 PM), called CNA1 into HR office and was explaining to employee was being suspended pending an allegation of abuse. CNA started saying, It was because R60 reported me, right? Resident does not like me because I am black, and should just say so. I was helping R40 in the bathroom and when removed resident's dirty diaper, the resident took it and shoved it in my face, I got upset and told resident don't do that. When CNA1 was asked if called R40 stupid, CNA stated, 'yes, I called the resident stupid because I was so upset about it. I have never called any other resident stupid, but I was so upset and R60 was making comments towards me.' I told CNA1 staff cannot call residents names and definitely cannot call them stupid. (CNA1) stated, 'What I am to do? (sic) Just take it, let the resident do what they want?' Informed employee could tell R40 that this behavior was not appropriate, and the employee should have reported it to a supervisor, me. I re-stated the employee would be suspended pending investigation. The report continued to document, in addition, CNA1 stated I don't care, I am done with my contract any ways and walked out of the office. As employee was walking past the nurse station, the employee turned to 300 hall, R40's hall, so I went down to make sure employee was leaving and not going into any resident's rooms. When I got to the beginning of the hall, I heard yelling from R40's room, I opened and employee was in there, R60 was yelling, 'get out of my room now' I went in and told employee could not be in the room and to get out, as the employee was walking out, the employee called R60 'ass hole'. Employee was yelling at R60, resident was agitated and stated ' I don't want the CNA in my room ever again. Resident was given reassurance and informed employee will not be working with resident or in the facility anymore. R60 calmed down. The form was signed by the Director of Nursing (DON). On 04/22/24 at 10:30 AM, R40 was observed sitting in resident's room. R40 was asked if remembered the incident between the resident and CNA1. Resident stated, yes. R40 was asked what happened that day. R40 stated, I was in the bathroom, and the CNA called me stupid. R40 was asked why CNA1 would call you stupid. R40 stated, I don't know. R40 was asked how this made the resident feel. R40 stated, I felt dumb. On 04/22/24 at 11:07 AM, R60 was asked what happened between CNA1 and R40. R60 stated, R40 was in the bathroom with the CNA, and I heard the employee say, What are you, stupid? Rage ran right through me. R40 told the SSD what happened, and the SSD got the Director of Nursing (DON) involved. On 04/23/24 at 2:28 PM, the DON stated, R60 had reported to me about what CNA1 said to R40. We found CNA1 in the supply room and brought employee into the Human Resources (HR) office. CNA1 was angry already. I was telling the employee about our process which involved being suspended pending the investigation. The DON further stated, It is our process to escort suspended or terminated staff out of the building however, we never had a chance as the employee started to escalate and get angrier. Employee stormed out of the HR office and slammed the door when leaving. I immediately went over to open the door and saw the employee going down the hallway to their room. By the time I got there, the CNA was in the resident's room, which is when I led the employee out the front door and told employee was terminated. The allegation of staff to resident verbal abuse was verified. On 04/23/24 at 3:15 PM, Nurse Aide in Training (NAT)1 was asked what the employee had witnessed that day when CNA1 entered the resident's room. NAT1 stated, I was in the room with CNA2 providing incontinent care to R60 when out of the blue, CNA1 barged into the room. CNA1 did not knock and came over to the foot of the bed. CNA1 was very angry and stated to R60, Do you have a problem with me? I told CNA1 to get back and go away, that is when the DON entered the room and led CNA1 out of the room. CNA1 then turned and told R60 the resident was a [expletive]. 2. Physical Abuse Resident 5 (R5) Review of the Admission Record revealed, R5 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, dementia, and anxiety disorder. Review of the admission MDS with an ARD of 12/13/23, revealed R5 had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact and had verbal behaviors nearly every day. Resident 57 (R57) Review of the Admission Record revealed, R57 was admitted to the facility on [DATE] with a diagnosis of Huntington's disease (an inherited condition in which nerve cells in the brain break down over time and results in progressive movement, thinking and psychiatric conditions.) Review of the quarterly MDS with an ARD of 11/01/23, revealed R57 had a BIMS score of zero out of 15 which indicated the resident was severely impaired in cognition and had physical and verbal behaviors nearly every day. Review of a Nursing Progress note dated 01/13/24 at 2:23 PM, documented CNA staff alerted nursing staff R5 was involved in an altercation. Upon responding to the scene, R5 was noted to be sitting in WC [wheelchair] in dining room. R5 was holding the head on the right side. R5 continued to have verbal behaviors towards staff and other female resident. CNA staff reported R5 was having inappropriate, verbal behaviors and directing aggressive comments to R57. Per dietary staff, R5 made comments throughout mealtime to other female resident, other female resident got up to get juice refilled, R5 continued to make comments to other resident, other resident pulled R5's hair, R5 kicked other female in the legs, both residents were having verbal outbursts . Review of the 01/17/24 Facility Investigation report provided by the Administrator documented, At around 1:00 PM, CNA6, alerted nursing staff R57 was involved in an altercation with R5. Both residents were in the dining room area in the memory lane neighborhood. Dietary Aide (DA)1 was cleaning the dining area and observed that R57 got up and started walking in the hallway. R5 was sitting at the resident's dining table and made a comment towards R57. DA1 stated did not understand what was said but then R57 turned around and grabbed R5 by the hair, pulled it and then let go immediately. R5 started screaming and turned around and kicked R57 in the legs. CNA6 heard the yelling and came to assist. As CNA6 got to the hall, observed R5 kick R57 in the legs. The residents were separated and redirected. The nurses were alerted and responded to assist. In addition, the Facility Investigation report revealed the following statements by R5 and R57: On 01/14/24, R57 was interviewed regarding the incident. R57 has limited verbal communication but was able to confirm remembered the incident. When asked what the resident remembered, R57 stated, 'I beat the resident up, I beat the resident up, the resident hit me first on the head.' R5 was interviewed regarding the incident/altercation. R5 stated, You mean the other day when I got beat up? Yes, the other resident beat me up! I was just sitting there in the dining room, and the resident walked up and grabbed me by the hair and pulled me, grabbed me by the neck and hit my head.' When R5 was asked if had said anything to R57, R5 replied, No! how could I, the resident was standing over me, I didn't have time to do anything, the staff came immediately and pulled the resident away and took the resident. On 04/22/24 at 9:30 AM, R5 was in the resident's room, sitting in a wheelchair. The resident refused to be interviewed. R5 had been moved to a different hall after the allegation. On 04/22/24 at 11:50 AM, R57 exited the resident's room, and walked to the dining table. The resident's gait was unsteady, and had flailing of the arms. No other resident in the dining room showed fear or concern as the resident walked by. R57 did not touch any other resident. R57 was non-interviewable. On 04/24/24 at 11:07 AM, the DON confirmed the resident-to-resident altercation between R5 and R57 was verified as physical abuse. The DON stated that both residents were separated and R5 was moved to a different hall. No further abusive situation with R5 had occurred since this episode. Resident 19 (R19) Review of the Admission Record revealed R19 was admitted to the facility on [DATE] with diagnoses that included dementia and schizophrenia (a serious mental condition involving a breakdown in the relation between thought, emotion, and behavior). Review of the quarterly MDS with an ARD of 01/05/24, revealed R19 had a BIMS score of 11 out of 15 which indicated the resident was moderately impaired in cognition and had no behaviors. Resident 130 (R130) Review of the Admission Record revealed R130 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury (TBI) and intellectual disabilities. Review of the quarterly MDS with an ARD of 12/12/23, revealed R130 had a BIMS score of 15 out of 15 which indicated the resident was cognitively aware and had no behaviors. Review of the 12/27/23 Facility Investigation report provided by the Administrator, documented, At approximately 1700 (5:00 PM), residents were in their room and CNA's heard loud voice from the room, door was closed, when CNA8 opened the door, residents were yelling at each other. R130 was in a hunch position in front of R19, looked like the resident was getting up from the floor. Both residents were in room entrance between the door and R19's bed. R130 stood up and threw some punches at R19. R19 was standing with arms up in a defense position, blocking the face and trying to stay away from R30. CNA8 got between both residents and separated them. A nurse was walking down the hallway and went in to help. R130 was removed from the room and the neighborhood. The Facility Investigation report further revealed, Upon body assessment, R130 was noted to have two red scratches on the left side of the neck, and redness to left side of upper chest measuring 17cm x 2 cm. R130 has an abrasion below right knee, no redness or swelling present. Area tender to touch. R130 stated was pushed by R19 and fell on the right knee. When asked about the scratches on the neck, resident stated might have scratched self, then said R19 probably scratched it. Review of an 02/18/24 Discharge Summary revealed, R130 is discharged today with a cousin and family. Family will be transferring the resident to another facility this afternoon. On 04/22/24 at 9:43 AM, R19 was asked about the altercation with R130. R19 stated, I already know not to hit anyone, but I was doing defense. R130 hit me first and they investigated it. They took the resident away and I have not seen the resident again. On 04/25/24 at 9:30 AM, the DON verified the physical abuse between R130 and R19. The DON confirmed R130 was relocated to another hall and had remained with 1:1 supervision until discharge. FRI #s: NV00070475, NV00070231 and NV00070486

Based on interview and record review, and review of the facility policy, the facility failed to thoroughly investigate an allegation of staff to resident verbal abuse for two (Residents (R)40, R60) of 10 residents reviewed for abuse. This failure placed the residents at risk of increased mental health issues, and a diminished quality of life. Findings included. Review of the facility policy titled, Abuse Prohibition, dated 07/23, revealed, .Investigation .Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes .Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident . Resident 40 (R40) Review of the Admission Record revealed R40 was admitted to the facility on [DATE] with diagnoses that included stroke with left-sided paralysis, bipolar disorder (a disorder associated with episode of mood swings ranging from depressive lows to manic highs), and affective mood disorder (marked disruptions in emotions.) Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/26/24, revealed R40 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicated the resident was moderately impaired in cognition, had no behaviors, required partial assistance for transfers and did not ambulate. Resident 60 (R60) Review of the Admission Record revealed R60 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a neurological disease), bipolar disorder, and post-traumatic stress disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event.) Review of the quarterly MDS with an ARD of 12/27/23 revealed, R60 had a BIMS score of 13 which indicated the resident was cognitively intact. Review of the 02/24/24 at 4:30 PM, Facility Investigation report provided by the Administrator, documented: .Reported by Registered Nurse (RN)1 R60 was making an allegation of abuse towards Certified Nurse Aide (CNA) 1. Social Services Director (SSD) went to talk with R60 and reported R60 stated, 'I heard CNA1 tell R40, 'What are you stupid?,' while CNA was assisting the resident in the bathroom. This writer went to talk to R40 and when I asked the resident if CNA1 had called the resident stupid, the resident stated, 'yes'. R40 was asked if was Ok, stated, 'yes, I am ok I asked the resident if anything else was said, and the resident stated 'No' the CNA just called me stupid. Resident did report that it made the resident sad . Further review of the Facility Investigation report revealed the only staff who provided written statements were, Nurse Aide in Training (NAT)1 and CNA2. No other staff members, who were present on the unit or nursing staff were interviewed at the time of the allegation. In addition, the Facility Investigation report revealed the SSD had spoken to two other residents on the unit, however, there was no documentation to show who these residents were, what questions were asked of them, and what their responses were. On 04/23/24 at 9:18 AM, the SSD was asked if had interviewed other residents, who may have been cared for by CNA1, to determine if there had been any other verbal abuse. The SSD stated, I did speak with two other residents; however, I did not document their names or what their responses were. On 04/23/24 at 9:19 AM, the Administrator stated was not here at the time of the allegation, however, was made aware of it. The administrator acknowledged the investigation was not complete after having read it. Refer: F600: Free from Abuse/Neglect, for additional information.

Based on record review, interviews and facility policy review, the facility failed to ensure 1 of 5 Certified Nursing Assistant's (CNA3) background check was completed prior to hire, out of 10 employee files reviewed. This failure had the potential to negatively impact all residents. Findings include: Review of facility policy titled, Abuse Prohibition and Reporting (Elder Justice Act), revised 04/02/19, revealed .Prevention of Abuse .2. Screening of potential employees will be conducted and hiring will be dependent upon screening result. Screening shall include .b. Health care workers background checks on all staff .d. Screen through Office of Inspector General (OIG) Exclusion database. Review of CNA3's employee file indicated CNA3's date of Hire (DOH) was 01/15/24. Review of the facility provided untitled and undated fingerprints indicated, CNA3's fingerprints were completed and re-mailed on 02/20/24. Review of the facility provided Employee Schedule dated 01/28/24-02/24/24, indicated CNA3 worked the following dates: 01/28/24, 02/03/24, 02/04/24, 02/10/24, 02/11/24, 02/17/24, 02/18/24 and 02/24/24. Review of the facility provided Employee Schedule dated 02/25/24-03/23/24, indicated CNA3 worked the following dates: 02/25/24, 03/02/24, 03/03/24, 03/09/24, 03/10/24, 03/16/24, 03/17/24, 03/22/24, and 03/23/24. Review of the facility provided Employee Schedule dated 03/24/24-04/20/24 indicated that CNA3 worked the following dates: 03/24/24, 03/25/24 10-10, 03/30/24, 03/31/24, 04/01/24, 04/06/24, 04/07/24, 04/08/24, 04/13/24, 04/14/24, 04/15/24, and 04/20/24. Review of the facility provided Employee Schedule dated 04/21/24-05/18/24, indicated CNA3 worked the following dates: 04/21/24, and 04/22/24. Review of the facility provided, undated Department of Health and Human Services Nevada Division of Public and Behavioral Health (DPBH) form, indicated no evidence of a signature of the applicant and/or proof of electronic fingerprint submission. Review of the facility provided email dated 02/17/24, documented, The Nevada Department of Health and Human Services (NVDHHS) automated background checks system received notification that fingerprints for CNA3 were taken on 02/17/24. Review of the facility provided, undated DPBH Person Summary,documented CNA3's current fitness determination: In process and Current Employment Status: Provisional. On 04/25/24 at 9:00 AM, the Human Resources (HR) Manager indicated the CNA3's fingerprints were completed prior to starting work; however, the manager indicated had to re-send the fingerprints back on 02/20/24 due to not having the originating agency identifier ([NAME]) code listed. The manager indicated has not received the results back yet. On 04/25/24 at 09:50 AM, the Administrator indicated when the fingerprints are completed, the facility sends them in, and the state sends back a letter letting the facility know if the staff can appeal or not. The administrator indicated if a background cannot be appealed, then the staff member must be let go. The administrator explained the state is behind on getting fingerprints completed.

Based on interview and record review, the facility failed to ensure the Food Service Supervisor had completed a course in food safety and management for 1 of 1 Food Service Managers (FSM) for the facility's only kitchen. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. Findings include: Review of the FSM's job description titled Food Service Supervisor's job description, dated 12/16/23 documented, Requirement: Food Protection Manager Certificate. Review of the FSM's employee file revealed a hire date of 12/12/23, with two or more years experience as a kitchen supervisor in a healthcare setting, and certificate of completion for a Certified Food Protection Manager course with an issue date of 04/24/24. On 04/22/24 at 7:44 AM, the FSM stated had two or more years experience as a Food Service supervisor in a healthcare setting and had completed a food protection managers course. A certificate of completion for a Certified Food Protection Manager course with an issue date of 04/24/24 was provided on 04/24/24. During a follow up interview on 04/25/24 at 7:38 AM, the FSM was asked about the issue date of 04/24/24 for the certificate of completion for the Certified Food Protection Manager course. The FSM stated couldn't find the certificate for the course previously taken, so had retaken the course.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident (R)26) of three residents reviewed for falls received services to prevent additional falls. R26 sustained multiple falls, including on 06/01/22, 07/08/22, and 08/15/22. The facility failed to conduct a thorough investigation and root cause analysis to identify possible contributing factors, the reason for the fall, and the need for new/different interventions to prevent further falls. After this failure, R26 sustained another fall, on 11/30/22, resulting in a hip fracture. Findings include: Review of R26's face sheet revealed R26 was admitted to the facility on [DATE]. Diagnoses included restlessness and agitation, cognitive communication deficit, and Alzheimer's Disease. Review of R26's Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired based on a Brief Interview for Mental Status (BIMS) of 1/15. Per this MDS, R26 needed extensive assistance for Activities of Daily Living (ADLs). Review of R26's comprehensive care plan, which was in place as of 06/01/22, revealed a problem, with a start date of 05/26/20, that R26 is at a high risk for falling related to history of falls. Bilateral Knee pain (History of Bilateral TKAs [Total Knee Arthroplasty]), CVA [Cerebrovascular Accident] with Left side weakness, unaware of cognitive and physical limits, Alzheimer's disease, Psychotic disorder with delusions due to know physiological conditions, and seizures. The goal was for R26 to have minimized risk for injury. Interventions included floor mats, a low bed, and for staff to provide visual and verbal reminders to call for assistance when getting out of bed. Review of R26's Event Report dated 06/01/22, revealed the resident had a fall on 06/01/22 at 4:36 PM in the television common area. Per the Event Report the fall was not witnessed. The Event Report revealed the resident tried to get into a recliner by self. The resident had a bump on the back of head .quarter sized raised area with red peri wound [area around wound]. There was no evidence indicating a thorough investigation or a root cause analysis into the reason for the fall was conducted. Review of the resident's care plan revealed no evidence that it was updated after this fall, or that new interventions were put in place to prevent further falls with injury. Review of R26's Event Report dated 07/08/22, revealed the resident had a fall on 07/08/22 at 11:45 AM in the dining room (common area adjoined with the television room). The fall was witnessed. The Event Report revealed the resident was sitting in the wheelchair and lost balance. The resident complained of a 6/10 pain level for pain to the right temple. There was no evidence indicating a thorough investigation or a root cause analysis into the reason for the fall was conducted. Review of the resident's care plan revealed no evidence that it was updated after this fall, or that new interventions were put in place to prevent further falls with injury. Review of R26's Event Report dated 08/15/22, revealed the resident had a fall on 08/15/22 at 3:36 PM in the television common area. The fall was unwitnessed, and the resident sustained a skin tear. The Event Report revealed the resident was sitting in the recliner. Per the report, the cause of the fall was resident has been agitated all day due to shower day. In response to this fall, the care plan was revised with an intervention to observe R26 for safety when in the day room. Review of R26's quarterly MDS, with an Assessment Reference Date (ARD) of 11/11/22 in the EMR, revealed R26 had a BIMS score of 0/15, indicating severe cognitive impairment. R26 exhibited physical and verbal behaviors one to three days during the review period. R26 required limited assistance with ambulating in room and extensive assistance for locomotion off the unit and transfers. Per the MDS, the resident's balance when moving from seated to standing, walking, and surface to surface transfers was not steady. Review of an Event Report dated 11/30/22, revealed R26 sustained a fall on 11/30/22 at 7:30 PM in the television common area that was unwitnessed. The Event Report revealed R26 was sitting in the wheelchair and suddenly got up and lost balance. Review of a Progress Note, dated 11/30/22 documented, found resident on the floor sitting on their bottom, leaning on the wall, next to the xmas [sic] tree, with 1 line scratch between the eyebrows, appears to be from the xmas [sic] tree. Resident was watching TV prior to fall but according to the CNA [Certified Nursing Assistant], suddenly got up and lost balance. Resident was aware and responsive, denies pain, able to move legs without complaining of pain, assisted to the w/c [wheelchair] with 2 person assist and transferred to bed with 2 person assist. Checked for pain while in bed and complained of pain where right hip was touched. Called paramedic to transfer to [local facility] for evaluation, Dr. [name] notified and [responsible party name] was notified. Review of the Hospital History and Physical Report dated 12/01/22, revealed R26 had multiple falls at [facility name] and was found to have acetabular [hip fx [fracture] .CT [cat scan\ of the pelvis with contrast demonstrated a comminuted [bone broken in more than two places] right acetabula fracture with nondisplaced fractures of the right superior and inferior pubic rami [pelvis]. Per the hospital report, the physician and responsible party agreed to treat the fracture with nonoperative management. The resident was readmitted to the facility on [DATE]. Review of a significant change MDS assessment with an ARD of 12/16/22, which was completed after the resident's return to the facility revealed that the resident had declined in Activities of Daily Living (ADL) ability. The resident now did not ambulate, required extensive assistance with bed mobility, and transfers did not occur. Review of R26's current Care Plan, last reviewed 02/22/23, revealed R26 is at a high risk for falling related to history of falls. The goal was to have minimized risk for injury related to falls this quarter. The most recent approach was dated 08/16/22, prior to the fall with fracture on 11/30/22. There was no evidence that R26's care plan was revised after the fall with fracture on 11/30/22, with additional interventions to prevent further accidents. An attempt to interview the resident on 03/06/23 at 10:45 AM revealed the resident was confused and could not answer questions, due to cognition. The resident expressed no memory of the fall. During the attempted interview, observation revealed the resident was in a low bed, with fall mats in place. During an interview with the Director of Memory Care Unit/Certified Nurse Aide (DMCU/CNA), on 03/08/23 at 8:19 AM, confirmed R26 had a fall on 11/30/22, and they were unable to reposition the resident in bed because the resident was in such pain. During an interview with the Director of Nursing (DON) on 03/08/23 at 9:03 AM, the DON stated when a resident fell , the Interdisciplinary Team (IDT) would normally meet the next business day to review the fall, determine the root cause and implement any possible interventions. The DON confirmed that, for the falls on 06/01/22, 07/08/22, and 11/30/22, the care plan was not updated with the fall or interventions added to prevent another fall and the facility could provide no evidence that a root cause analysis was conducted. During an interview with the MDS Coordinator (MDSC), on 03/08/23 at 2:00 PM, the MDSC stated normally completed the care plan and would add updates to the care plan when a resident fell . The MDSC stated when a resident fell , the IDT would discuss the fall and develop interventions, which would then add to the care plan. The MDSC explained the care plan was important because it was our basis of care for the resident. The MDSC confirmed there were no updates on the care plan in response to three of the resident's four falls, including the fall with fracture. During an interview with Licensed Practical Nurse (LPN) 1, on 03/09/23 at 10:20 AM, the LPN was not aware of any new interventions implemented for the resident after each of the falls. During an interview with Certified Nurse Aide (CNA) 2, on 03/09/23 at 10:35 AM, the CNA was not aware of new interventions implemented for the resident after his falls. During an interview with CNA1, on 03/09/23 at 1:05 PM, the CNA revealed R26 will have fits and will need to be monitored. The CNA explained the day of the 11/30/22 fall, had observed R26 moving up and down in the chair while the CNA was assisting other residents from the dining room back to their room, when R26 fell into the Christmas tree. CNA1 confirmed did not see the resident's fall, as was pushing another resident in their wheelchair back to their room. CNA1 stated when had helped R26 get into bed after the fall on 11/30/22, R26 indicated was in pain because was calling out. The CNA stated was not aware of any additional interventions to prevent accidents after the resident's previous falls. During an interview with the DON and the Administrator, on 03/09/23 at 3:15 PM, they stated that the facility had no policies related to fall investigations. They referenced an Emergency Policy, however, review of this policy, dated 04/03/18, revealed it did not indicate the need for an investigation to be completed after each fall, did not indicate that a root cause analysis should be completed in response to the fall, and did not call for interventions to be implemented after each fall to prevent further accidents. Further interview with the DON revealed that the facility had provided all documentation related to all of R26's falls, and confirmed the facility had no further evidence that each of the resident's falls had been thoroughly investigated with the determination of a root cause.

Based on observation, interview, and record review the facility failed to ensure five of 12 reviewed residents who resided on the secure unit (Resident (R) 41, R26, R36, R 34, and R43) were free from the potential for involuntary seclusion. The facility failed to ensure all required actions were taken to ensure appropriate placement on the secured unit. Specifically, the facility failed to ensure each resident's clinical record included the required documentation: Evidence of the clinical criteria for placement in the secure unit by the resident's physician and the interdisciplinary team (IDT). Evidence reflecting the resident/representative involvement in the resident's placement in secure unit. Documentation by the IDT of the impact and/or reaction of the resident while residing on the secure unit; and ongoing documentation of the resident's care plan to ensure the resident continued to meet the criteria to remain in the secure unit. Findings include: Review of the undated Requirements for Memory Care Unit. Document revealed, The Resident will have a diagnosis of Dementia or Alzheimer's Disease or be at risk for elopement. 1. Observation on 03/06/09 at 10:00 AM during initial tour, R41 was observed to reside on the secure unit. The resident was talking to the director of the unit, who was finding a movie for the resident. The resident was calm and displayed no behaviors. Review of R41's face sheet revealed R41 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia. At the time of admission, the resident was on a regular unit in the facility and did not reside in the facility's locked (secure unit). Review of R41's Progress Notes dated 01/17/23 revealed, Brief Interview for Mental Status (BIMs) score was a 02 - Severe Impairment, resident is recommended for [secure unit name]. Review of R41's EMR revealed no documentation from the physician indicating R41 met the clinical criteria to reside on the secure unit. Review of the Memory Care Screening Form dated 02/01/23, revealed R41 had a diagnosis of Dementia. Additional observations included, pleasant and eager to move to [city name] eager to start rehab and be able to ambulate .Informed resident we would like to rehab first in general area then transfer to Memory Care if appropriate with mobility, Resident was really pleasant and a little confused. The Memory Care Screening Form revealed R41 does not meet [secure unit] admission criteria .will need physical improvement first. Per the form, approved for placement on [secure unit Name] placement: not at present time, will be able to transfer when more mobile. The form was signed by the Director of Memory Care Unit/Certified Nurse Aide (DMCU/CNA), on 02/01/23. There was no evidence that the determination that the resident should be moved to the secure unit was made by an interdisciplinary team (IDT), and no other staff signatures were on the form. Review of R41's Progress Notes dated 02/06/23 (late entry on 03/08/23) revealed, reviewed with resident about transferring to Memory Lane as previously discussed prior to transfer to facility. Although no further Memory Care Screening Form was completed, a review of R41's Progress Notes, dated 02/09/23, revealed, [Resident name] was admitted to Memory Lane on 02/09/23. Review of R41's EMR revealed no evidence that the resident or their representative were involved in the determination to move the resident to the secure unit. There was no documentation by the IDT of the impact and/or reaction of the resident while residing on the secure unit; and ongoing documentation of the resident's care plan to ensure the resident continued to meet the criteria to remain in the secure unit. 2. Observation on 03/06/09 at 10:00 AM during initial tour revealed R26 resided on the secure unit. Review of R26's face sheet revealed R26 was admitted to the facility on [DATE]. Diagnoses included restlessness and agitation, cognitive communication deficit fracture of right acetabulum and Alzheimer's Disease. R26 was receiving Hospice services. A review of R26's EMR revealed there was no evidence of the clinical criteria for placement in the secure unit by the resident's physician and the IDT; no evidence reflecting the resident/representative involvement in the resident's placement in secure unit; no documentation by the IDT of the impact and/or reaction of the resident while residing on the secure unit; and no ongoing documentation of the resident's care plan to ensure the resident continued to meet the criteria to remain in the secure unit. 3. Observation on 03/06/09 at 10:00 AM during initial tour, revealed R36 resided on the secure unit. Review of R36's face sheet revealed R36 was admitted to the facility on [DATE]. Diagnoses included dementia and depressive episodes. A review of R36's EMR revealed there was no evidence of the clinical criteria for placement in the secure unit by the resident's physician and the IDT; no evidence reflecting the resident/representative involvement in the resident's placement in secure unit; no documentation by the IDT of the impact and/or reaction of the resident while residing on the secure unit; and no ongoing documentation of the resident's care plan to ensure the resident continued to meet the criteria to remain in the secure unit. 4. Observation on 03/06/09 at 10:00 AM during initial tour revealed R34 resided on the secure unit. Review of R34's face sheet revealed R34 was admitted to the facility on [DATE]. Diagnoses included vascular dementia with behavior disturbance and major depressive disorder. A review of R34's EMR revealed there was no evidence of the clinical criteria for placement in the secure unit by the resident's physician and the IDT; no evidence reflecting the resident/representative involvement in the resident's placement in secure unit; no documentation by the IDT of the impact and/or reaction of the resident while residing on the secure unit; and no ongoing documentation of the resident's care plan to ensure the resident continued to meet the criteria to remain in the secure unit. 5. Observation on 03/06/09 at 10:00 AM during initial tour revealed R43 resided on the secure unit. Review of R43's face sheet revealed R43 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia, mild with anxiety. A review of R43's EMR revealed there was no evidence of the clinical criteria for placement in the secure unit by the resident's physician and the IDT; no evidence reflecting the resident/representative involvement in the resident's placement in secure unit; no documentation by the IDT of the impact and/or reaction of the resident while residing on the secure unit; and no ongoing documentation of the resident's care plan to ensure the resident continued to meet the criteria to remain in the secure unit. During an interview with the Social Service Director (SSD) on 03/08/23 at 9:42 AM, the SSD stated would talk to the family about their loved one residing on the secure unit but did not specifically document the conversation. The SSD revealed there were residents that reside in the facility that have dementia or Alzheimer's who have refused to live on the secure unit. During an interview with the Minimum Data Set Coordinator (MDSC), on 03/08/23 at 2:00 PM, stated the MDSC normally completed the care plans and added updates when needed and indicated there should be a care plan related to the placement on the secure unit for every resident who resided on the unit. The MDSC stated currently does not have a care plan for each resident residing on the secure unit, that was specific to the secure unit and confirmed that there should be. The MDSC stated the care plan was important because it was our basis of care for the resident. The MDSC confirmed should have completed the care plans for this area but did not. During an interview with the Director of Nursing (DON) on 03/07/23 at 12:26 PM, the DON stated, We don't have a policy for the secure unit. During an additional interview with the DON on 03/09/23 at 10:00 AM, the DON indicated all required documentation should be included in each resident's EMR if they reside in the secure unit. The DON confirmed all documentation for the five reviewed residents had been provided to the survey team, and there was no additional evidence of the required documentation. During an interview with the Administrator on 03/09/23 at 3:30 PM, the Administrator confirmed that all required documentation should be included in each resident's EMR if they resided on the secure unit.

Based on interview, record review, and review of facility policy, the facility failed to provide written notice of transfer to the resident and/or the resident's representative for two (Resident (R) 31 and R26) of two sampled residents reviewed for transfers. The facility failed to provide the required written notice, which includes information about the reason, date, and location of the transfer, as well as information on how to appeal the transfer, when the two residents were transferred to another health care facility. Findings include: Review of the facility policy titled, Transfer of a Resident, revised 06/01/22, revealed, Hospital transfers shall be initiated after nursing has contacted the attending physician regarding a resident's health. Upon order by the physician to transfer a resident to the hospital, the family and/or resident representative, and the hospital shall be notified. A transfer form shall be completed by nursing and accompany the resident to the hospital, along with all appropriate resident documents, including advance directives and the bed hold policy. 1. Review of R31's face sheet revealed an admitted [DATE], with medical diagnoses that included but were not limited to chronic diastolic (congestive) heart failure, dementia with other behavioral disturbance, and emphysema. Review of the Progress Notes dated 02/20/23 at 9:32 AM, revealed the resident was transferred to a psychiatric hospital for evaluation. Review of the resident's clinical record revealed no evidence that a written notice, which contained all required information including the reason and effective date for the transfer, the location to which the resident was transferred, and information about the resident's appeal rights and how to contact the Long-Term Care Ombudsman, was provided to either the resident and/or their representative. 2. Review of R26's face sheet revealed R26 was admitted to the facility on [DATE]. Review of a Progress Note dated 11/30/22, revealed the resident was found on the floor sitting on the resident's bottom, leaning on the wall, next to the xmas [sic] tree .Checked for pain while in bed and complained of pain where right hip was touched. Called paramedic to transfer to [local hospital] for evaluation, Dr. [name] notified and [responsible party name] was notified. Review of the resident's EMR revealed no evidence that a written transfer notice was provided to both the resident and their responsible party. During an interview on 03/07/23 at 2:59 PM, Licensed Practical Nurse (LPN) 3 stated when a resident is transferred to the hospital, nursing staff completes the CCD (Continuity of Care Document). Per LPN3, the CCD form is provided to the paramedic, and contains the resident diagnosis, medications, and code status. Review of the CCD form referenced by LPN3 revealed this form did not provide all information required to be included in a written transfer notice. During an interview on 03/07/2023 at 3:03 PM, the Business Manager (BM) stated, When a resident leaves for the hospital, we wait to see if the resident will be admitted or just observed. We do not do a transfer form. During an interview with the Director of Nursing (DON), on 03/08/23 at 11:20 AM, the DON stated that although they did provide a form that states the facility's bed hold policy, they did not complete a transfer form when a resident was transferred to another facility and was unaware one was required per regulation and facility policy. The DON further stated, I will make sure we create a document to reflect the information needed per Federal regulation and our facility policy. During an interview with the Administrator, on 03/08/23 at 03:55 PM, the Administrator stated the expectation of facility staff is to provide a written document outlining the reason for transfer, as well as a bed hold policy to all transferring residents. The Administrated further stated, We now realize the process we had in place was not sufficient, and in the future, we will implement all requirements and follow Federal and facility policy.

Based on interview, record review, and policy review, the facility failed to complete a comprehensive resident assessment within 14 calendar days after admission for one (Resident (R) 102) in a sample size of 18 residents. The failure to complete the Admission Assessment within 14 days of admission creates the potential for a delay in identification of the resident's care needs. Findings include: Review of the facility's policy titled MDS [Minimum Data Set] Completion, revised 08/2020 indicated, The comprehensive admission assessment will be completed within 14 days after admission, excluding readmissions in which there is no significant change. Review of CMS's (Center for Medicare and Medicaid Services) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated 10/2019, revealed, Assessment Reference Date (ARD) (Item A2300) No Later Than 14th calendar day of the resident's admission (admitted + 13 calendar days). Review of R102's face sheet, revealed an admitted [DATE] with medical diagnoses that included but were not limited to effusion, right knee, other tear of unspecified meniscus, current injury, right knee, subsequent encounter, hypertensive heart disease with heart failure, dementia, psychotic disturbance, mood disturbance, and anxiety. Review of R102's admission MDS with an Assessment Reference Date (ARD) of 02/22/23, revealed the assessment was started but not completed as of the start date of the survey which began on 03/06/23. The status for this survey indicated it was In Process. During an interview on 03/07/23 at 4:15 PM, the MDS Coordinator stated that the time frame for an admission MDS was 14 days from the date of admission. When asked the completion date of the MDS for a resident with an admitted [DATE], the MDS Coordinator was unable to say. The MDS Coordinator stated, I think an entry is on day 7 and admission is on day 14. The MDS Coordinator stated that staff know the admitted and the staff knows when to do their section. The MDS Coordinator stated, I know by my list [when an MDS is completed] and that the MDS is not signed. During an interview on 03/07/23 at 4:55 PM the MDS Coordinator was asked about R102's MDS assessment being past due. The MDS Coordinator stated, I know I am behind on some of them. During an interview on 03/08/23 at 8:24 AM, the Director of Nursing (DON) stated, MDSs are completed during admission when there is a significant change, quarterly and annually. The DON further stated, after the ARD, you have eight days from the ARD date to start gathering data, and the MDS should be completed within 14 days of the admitted . The DON explained for a resident with an admitted [DATE], the admission MDS should be completed on the 28th of February. The DON stated that the MDS Coordinator monitors the time frames and accuracy, and the expectation is that staff follow the facility policy and Federal guidelines that all MDS's are completed by the due date. During an interview on 03/08/23 at 8:42 AM, the facility Administrator stated, MDSs are time sensitive, and the expectation is that facility staff follow facility policy and CMS guidelines that they are completed timely and accurately.

Based on observation, interview and record review, the facility failed to: 1) Identify an off label medication dosing schedule and document there was a specific clinical need for the use of the medication for 1 of 15 sampled residents (Resident #2). 2) Identify, evaluate and report medication side effects as potentially being associated with a resident decline in status in 1 of 15 residents (Resident #2). 3) Obtain monitoring tests related to assuring appropriate medication dose adjustments in 2 of 15 residents (Resident #2, #1). Findings include: 1) Identify an off label medication dosing schedule and document there was a specific clinical need for the use of the medication. Resident #2 Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was able to maneuver and pilot an electric wheel chair with limited movement of the right arm. Review of the medical record of Resident #2 revealed the following: - A signed physician progress notes [REDACTED]. - The resident was taking Roperinole(sic) 2-4 mg (milligrams) at 8:00 AM, 12:00 PM, 3:00 PM and 8:00 PM for restless leg syndrome (RLS). - A second physician progress notes [REDACTED]. Dosage: 2 mg tablet extended release 24 hours. Take one tablet by mouth four times a day. - The current physician orders [REDACTED]. - The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/23/13 at 9:10 AM, the Director of Nursing (DON) and the consulting pharmacist confirmed the [DIAGNOSES REDACTED]. The employees confirmed the resident was receiving the Ropinirole for restless leg syndrome. The pharmacist acknowledge the dosing schedule for Ropinirole was in the upper dosing limits and the resident should have been receiving three to six milligrams three times a day. The pharmacist expressed concern with the current dosing schedule of Ropinirole and acknowledged upper limit dosing had not been identified. The medical record of Resident #2 indicated the resident had been receiving the Ropinirole since 4/12/13. The Medication Administration History of Resident #2's Ropinirole revealed the resident was receiving the medication four times a day at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. The resident was receiving the Ropinirole 2 mg every four hours during the day. Resident #2's Medication Administration History revealed 17 Ropinirole late administrations occurred between 8/1/13 at 8:00 AM through 8/21/13 at 12:00 PM. The record documented the following: - 8/2/13 due 4:00 PM given 5:44 PM - 8/4/13 due 8:00 AM given 9:07 AM - 8/6/13 due 8:00 AM given 9:32 AM - 8/6/13 due 4:00 PM given 5:02 PM - 8/9/13 due 4:00 PM given 5:41 PM - 8/10/13 due 4:00 PM given 5:33 PM - 8/11/13 due 8:00 AM given 9:00 AM - 8/11/13 due 4:00 PM given 5:34 PM - 8/11/13 due 8:00 PM given 9:47 PM - 8/12/13 due 4:00 PM given 5:32 PM - 8/13/13 due 8:00 PM given 10:06 PM - 8/14/13 due 12:00 PM given 1:12 PM - 8/15/13 due 4:00 PM given 5:11 PM - 8/18/13 due 4:00 PM given 5:31 PM - 8/19/13 due 4:00 PM given 5:12 PM - 8/20/13 due 8:00 AM given 9:46 AM - 8/21/13 due 8:00 AM given 10:12 AM According to the Mosby's 2012 Nursing Drug Reference book, the Ropinirole reaches peak concentration within one to two hours after administration and the half life of the medication was six hours. The every four hour dosing could result in a 50% drug concentration remaining in the resident at the time of the next administered dose during the day. Medications administered late have the potential to further increase the drug concentration in the resident relative to the time the next dose was given. The medical record of Resident #2 lacked documented evidence the physician was notified of the late Ropinirole administrations. According to the Mosby's Ropinirole was used for adults with [MEDICAL CONDITION]. The recommended dose for [MEDICAL CONDITION] was 0.25 mg three times daily titrated weekly to a maximum of 24 mg per day. The recommended dose for restless leg syndrome was 0.25 mg one to three hours before bedtime, may increase dose until symptoms resolve. According to GlaxoSmithKline (December 2012) Patient Information (Ropinirole tablet) sheet: - People with RLS should take this medication once daily one to three hours before bedtime. - Ropinirole may cause serious side effects including: falling asleep during normal activities, decrease in blood pressure, [MEDICAL CONDITION], hallucinations and dyskinesia (involuntary muscle movement) may be caused or exacerbated. The medical record of Resident #2 lacked documented evidence as to the rational behind the current dosing schedule of Ropinirole to treat RLS. The medical record lacked documented evidence the dosing schedule was identified or addressed by nursing staff, the physician or the pharmacy consultant. 2) Failure to identify, evaluate and report Resident #2's decline in status which included ongoing [MEDICAL CONDITION], decreased right upper limb mobility resulting in resident being denied access to electric wheel chair and verbal expression of end of life thoughts as being associated with potential medication side effects. Review of the medical record of Resident #2 revealed the following: - physician progress notes [REDACTED]. Furthermore, the resident was able to independently maneuver and pilot an electric wheel chair. - physician progress notes [REDACTED]. The record further indicated the resident remained able to maneuver and pilot an electric wheel chair. - In addition to the Ropinirole (which has a side effect of low blood pressure) the record contained a physician order [REDACTED]. - The blood pressure assessments between 8/1/13 through 8/22/13, revealed the resident had eight incidents of low blood pressure. In addition the resident's heart rate was low on six occasions (normal adult heart rate (HR) is 60 - 100 beats per minute) during this time frame. Results revealed the following: - No documentation of BP or HR between 8/1/13 through 8/7/13. - 8/8/13 BP= 98/61 HR=56 - 8/9/13 BP=100/50 Time 3:16 AM - 8/9/13 BP=86/50 HR=58 Time 8:37 AM - 8/10/13 BP=100/80 - 8/14/13 BP=98/58 - 8/18/13 HR=50 - 8/19/13 BP=100/50 HR=55 Time 2:20 AM - 8/19/13 BP=104/62 HR=55 Time 8:08 PM - 8/22/13 BP= 96/55 HR=55 The nursing progress notes of Resident #2 (between the dates 8/1/13 through 8/22/13) revealed the following information: - No documented notes between 8/1/13 through 8/6/13. - 8/7/13, Resident scraped right arm along wall while up in electric wheel chair. - 8/7/13, Resident reported severe neck pain and decreased ability to move extremities (side effect of Ropinirole) as usual. BP =76/48. -8/7/13, during an out of facility activity the resident had gone unresponsive for five to ten minutes. Resident was able to be awakened by shaking and calling residents name. BP=98/61, HR=56. Resident reported falling asleep (side effect of Ropinirole). - 8/18/13, HR=50, Resident reports muscle spasm pill was making heart rate low and refused pill. - 8/19/13, Patient (Pt) unable to maneuver electric scooter independently. Pt asked staff to help stop and to move the scooter with the controls. Pt would use manual wheel chair until further evaluation. - 8/19/13, had an episode of unresponsiveness this month. Monitoring BP's had been running low. Recently upset the w/c (wheel chair) was not working properly and needed staff assist. Was total assist with activities of daily living. Was able to move right hand/arm slightly. - A facility physician referral form dated 8/8/13, revealed the physician had been notified of the initial low BP, HR and unresponsiveness on 8/8/13. The form also documented the resident was having thoughts of death and was mad because the staff awakened the resident while the resident claimed to be near death. This information was not documented anywhere else in the resident's medical record. The physician did not make any changes to the residents current treatment plan. - The medical record lacked documented evidence the facility performed any interventions or further assessments related to the resident's alleged near death experience or thoughts of death. Resident #2's [MEDICATION NAME] Administration Record revealed: - 8/9/13 refused [MEDICATION NAME]. - 8/10/13 refused [MEDICATION NAME]. - 8/11/13 refused [MEDICATION NAME]. - 8/12/13 refused [MEDICATION NAME]. Resident reported medication lowers BP too much. - 8/13/13 [MEDICATION NAME] not administered due to low BP. - 8/18/13 refused [MEDICATION NAME] due to low BP from [MEDICATION NAME] (a muscle relaxant with side effects including [MEDICAL CONDITION]) - 8/19/13 refused [MEDICATION NAME]. - 8/20/13 refused [MEDICATION NAME]. - A physician referral form dated 8/12/13 revealed the physician had been notified of the residents initial refusal to take [MEDICATION NAME] because of low BP of 88/56. The form also documented the residents belief the muscle spasm medication was also a problem with causing low BP. The form included signed orders dated 8/14/13, reading, If BP is constantly low then discontinue [MEDICATION NAME]. The medical record lacked documented evident the facility notified the physician of the residents ongoing refusal of medications, low heart rate and low blood pressures. The medical record of Resident #2 documented the [MEDICATION NAME] had not been discontinued and the resident was still receiving the [MEDICATION NAME] as of 8/22/13. According to the Mosby's 2012 Nursing Drug Reference book, side effects of [MEDICATION NAME] include: depression, [MEDICAL CONDITION], abnormal physical weakness. The reference recommendations for [MEDICATION NAME] include: monitoring of heart rate before medication administration and blood tests including complete blood count, liver, kidney and electrolyte blood tests be performed on a periodic basis. On 8/20/13 in the morning, Resident #2 was observed in bed with eyes closed. An electric wheel chair was observed near the sink in the room. A white 8 x 10 inch paper was sitting on the seat of the chair with writing in large letters which read, "Resident restricted from using electric w/c (wheel chair) d/t (due to) decreased ability and ROM (range of motion) to Rt (right) upper arm." A manually operated w/c was observed next to the electric w/c. On 8/21/13 later in the morning, Resident #2 reported feeling frustrated and upset because of being "banned from using the electric w/c, and having to use the manual w/c. The resident explained the manual chair was not able to meet needs because it was too painful to sit in due to cervical/spinal disease process. The resident acknowledged having difficulty moving the electric chair due to changes in ability to move right arm and hand and this resulted in the resident not being able to control the w/c. The resident reported the changes in arm mobility had not been evaluated. The resident then began to cry and expressed frustration and sadness. The resident stated, "I don't feel like my needs are being met here (referring to the skilled nursing facility) and I need my family." 3) Failure to obtain laboratory monitoring tests as ordered by the physician in order to make appropriate medication dose adjustments. According to the Mosby's 2012 Nursing Drug Reference book, recommendations for [MEDICATION NAME] include: monitoring of heart rate before medication administration and baseline and periodic blood tests including complete blood count, liver, kidney and electrolyte blood tests be performed. The medical record of Resident #2 lacked evidence of consistent monitoring of heart rate prior to [MEDICATION NAME] administration. The medical record of Resident #2 lacked evidence baseline blood work was obtained upon admission 4/12/13. Resident #2's record did contain a Pharmacy Consultation Report dated 7/22/13. The report indicated the resident had not had an assessment of renal function and recommended monitoring lab work every six months in order for appropriate dosing adjustment to be made. The report documented the physician accepted the pharmacy recommendation and ordered additional blood work. The order was dated and signed by the physician on 8/12/13. The medical record lacked documented evidence the blood test had been performed. On 8/21/13 at 11:10 AM, the Director of Nursing (DON) acknowledged the blood tests results were not in the record of Resident #2. The DON explained the process of receiving physician orders [REDACTED]. The DON reported it appeared as if the blood tests had not been correctly entered into the computer and therefore had not been performed. The DON was unable to describe a process of checks and balances whereby these deficient practices related to laboratory monitoring could be identified and corrected by facility staff. Facility Policy No. 3.17 titled Pharmaceutical Procedures (Revised 2/13) revealed the following: - Page 10 of 19, Medication Errors and Adverse Reactions - A. Medication Errors are defined as:..wrong time. Medication errors should be reported to the resident's physician as soon as possible. -B. Adverse Consequences 1. Refers to an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. It may include and adverse drug reaction which may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic and helpful effects of the medication or any response to a medication that is noxious and unintended. If after evaluation by the physician, he/she believes an adverse drug reaction has occurred; an entry will be made in the resident's record identifying an allergy to the medication. -2. A side effect is an expected, well known reaction that occurs with a predictable frequency and may or may not rise to the level of being an adverse consequence. The medical record of Resident #2 lacked documented evidence indicating the nursing staff, consulting pharmacist and physician, identified, evaluated and intervened during the multiple adverse consequences experienced by Resident #2 while receiving unnecessary dosing with [MEDICATION NAME] and Ropinirole. Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record of Resident #1 revealed the resident was receiving the medication [MEDICATION NAME] 20 mg (milligrams) every morning and [MEDICATION NAME] 25 mg twice daily. Resident #1's record indicated the potassium levels were most recently evaluated on 8/22/12, one year ago. On 8/21/13 at 3:10 PM, the Director of Nursing explained potassium levels are monitored every 12 months. On 8/23/13 at 9:10 AM, the Pharmacist explained residents who receive [MEDICATION NAME] have their potassium levels monitored every six months. Facility Policy titled Pharmaceutical Procedures (Revised 2/13) indicated all residents receiving diuretics should have serum electrolyte levels done every six months. Resident #1's medical record lacked documented evidence serum electrolyte levels were monitored every six months.

Based on observation, interview and record review, the pharmacist failed to identify, evaluate and report medication dosing irregularities which resulted in going hypotension in 1 of 15 residents (Resident #2). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record of Resident #2 revealed the following: - A signed physician progress notes [REDACTED]. - The progress note indicated the resident was taking Roperinole(sic) 2-4 mg (milligrams) at 8:00 AM, 12:00 PM, 3:00 PM and 8:00 PM for restless leg syndrome (RLS). - A second physician progress notes [REDACTED]. Dosage: 2 mg tablet extended release 24 hours. Take one tablet by mouth four times a day. - The current physician orders [REDACTED]. - The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 8/23/13 at 9:10 AM, the consulting pharmacist confirmed the [DIAGNOSES REDACTED]. The pharmacist confirmed the resident was receiving the Ropinirole for restless leg syndrome. The pharmacist acknowledge the dosing schedule for Ropinirole was in the upper dosing limits and the resident should have been receiving three to six milligrams three times a day. The pharmacist expressed concern with the current dosing schedule of Ropinirole and acknowledged the dosing had not been identified. The medical record of Resident #2 indicated the resident had been receiving the Ropinirole since 4/12/13. The Medication Administration History of Resident #2's Ropinirole revealed the resident was receiving the medication four times a day at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM. The resident was receiving the Ropinirole 2 mg every four hours during the day. According to the Mosby's Ropinirole is used for adults with Parkinson's disease. The recommended dose for Parkinson's disease was 0.25 mg three times daily titrated weekly to a maximum of 24 mg per day. The recommended dose for restless leg syndrome is 0.25 mg one to three hours before bedtime, may increase dose until symptoms resolve. According to GlaxoSmithKline (December 2012) Patient Information (Ropinirole tablet) sheet: - People with RLS should take this medication once daily one to three hours before bedtime. - Ropinirole may cause serious side effects including: falling asleep during normal activities, decrease in blood pressure, fainting, and dyskinesia (involuntary muscle movement) may be caused or exacerbated. The medical record of Resident #2 lacked documented evidence as to the rational behind the excessive dosing schedule of Ropinirole to treat RLS. The medical record lacked documented evidence this excessive dose schedule was identified or addressed by the pharmacy consultant. Resident #2's Medication Administration History revealed 17 Ropinirole late administrations occurred between 8/1/13 at 8:00 AM through 8/21/13 at 12:00 PM. The record documented the following: - 8/2/13 due 4:00 PM given 5:44 PM - 8/4/13 due 8:00 AM given 9:07 AM - 8/6/13 due 8:00 AM given 9:32 AM - 8/6/13 due 4:00 PM given 5:02 PM - 8/9/13 due 4:00 PM given 5:41 PM - 8/10/13 due 4:00 PM given 5:33 PM - 8/11/13 due 8:00 AM given 9:00 AM - 8/11/13 due 4:00 PM given 5:34 PM - 8/11/13 due 8:00 PM given 9:47 PM - 8/12/13 due 4:00 PM given 5:32 PM - 8/13/13 due 8:00 PM given 10:06 PM - 8/14/13 due 12:00 PM given 1:12 PM - 8/15/13 due 4:00 PM given 5:11 PM - 8/18/13 due 4:00 PM given 5:31 PM - 8/19/13 due 4:00 PM given 5:12 PM - 8/20/13 due 8:00 AM given 9:46 AM - 8/21/13 due 8:00 AM given 10:12 AM The medical record of Resident #2 lacked documented evidence the pharmacist had identified any concerns with the consistent late dosing of Ropinirole. Review of the medical record of Resident #2 revealed the following: - In addition to the Ropinirole (which has a side effect of low blood pressure) the record contained a physician order [REDACTED]. - The blood pressure assessments between 8/1/13 through 8/22/13, revealed the resident had eight incidents of hypotension (low blood pressure). In addition the resident's heart rate was low on 6 occasions (normal adult heart rate (HR) is 60 - 100 beats per minute). Results revealed the following: - No documentation of BP or HR between 8/1/13 through 8/7/13. - 8/8/13 BP= 98/61 HR=56 - 8/9/13 BP=100/50 Time 3:16 AM - 8/9/13 BP=86/50 HR=58 Time 8:37 AM - 8/10/13 BP=100/80 - 8/14/13 BP=98/58 - 8/18/13 HR=50 - 8/19/13 BP=100/50 HR=55 Time 2:20 AM - 8/19/13 BP=104/62 HR=55 Time 8:08 PM - 8/22/13 BP= 96/55 HR=55 Resident #2's Lisinopril Administration Record revealed: - 8/9/13 refused Lisinopril. - 8/10/13 refused Lisinopril. - 8/11/13 refused Lisinopril. - 8/12/13 refused Lisinopril. Resident reported medication lowers BP too much. - 8/13/13 Lisinopril not administered due to low BP. - 8/18/13 refused Lisinopril due to low BP. - 8/19/13 refused Lisinopril. - 8/20/13 refused Lisinopril. Facility Policy No. 3.17 titled Pharmaceutical Procedures (Revised 2/13) revealed the following: B. Adverse Consequences - 1. Refers to an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. It may include and adverse drug reaction which may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic and helpful effects of the medication or any response to a medication that is noxious and unintended. - 2. A side effect is an expected, well known reaction that occurs with a predictable frequency and may or may not rise to the level of being an adverse consequence. - Review of Medication B. The consultant pharmacist will review the medical records of all residents monthly. This review will be done in the facility and will include the physician orders, laboratory tests and Medication administration records. The pharmacist will determine if there are significant irregularities present which could cause potential adverse reactions allergies [REDACTED]. The medical record of Resident #2 lacked documented evidence indicating the consulting pharmacist identified, evaluated and reported the multiple dosing irregularities and adverse consequences experienced by Resident #2 and associated with Lisinopril and Ropinirole.

Based on interview, document review, and policy review, the facility did not ensure nursing staff responded appropriately when 1 of 6 residents fell (Resident #5). Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record was reviewed on 01/18/2012. The event report stated in the "event information" section, that Resident #5 fell on [DATE] at 10:55., "What was resident doing just prior to fall? laying in bed". The nurse, Employee #5, documented "This writer was walking down hallway past resident's room and noted both CNAs (Certified Nursing Assistant) in with resident. Resident noted to be lying in bed, bed noted to be in high position. CNA stated to this writer that 'I forgot to put the bed down when I went to answer a tab alarm and came back and (Resident #5) was on the floor'. Floor mat noted next to bed. Unable to note if resident landed on floor mat or which position resident was in while on the floor due to CNAs had already lifted resident back in bed... MD notified via fax." In the "notes" section of Resident #5's event report, a nurse documented on 02/19/2011 at 9:47 PM, "Resident total assist with transfers. Resident was leaning in her (wheelchair) toward the right. Resident rubbing her left upper leg. Tylenol given per (as needed) order for discomfort, guarding left upper leg with (range of motion)... will continue to monitor." In the "notes" section of Resident #5's event report, the nurse documented on 02/20/2011, at 6:25 AM, that Resident #5 was "crying with movement or any touch to LT hip/femur area. Unable to assess for deformity secondary to pt (patient) discomfort. Large hematoma lateral RT (right) forearm bruising to LT (lower extremity). Call to (physician) orders received to transport (to emergency room )..." Resident #5 underwent an open reduction internal fixation for a [MEDICAL CONDITION]. The Director of Nursing (DON), Employee #3, was interviewed on 01/26/2012 at 1:40 PM. The DON stated the Certified Nursing Assistants should not have touched or moved Resident #5 until the nurse assessed her. The DON stated the resident did not have pain during the initial assessment on 02/19/2011 at 10:55 AM, so the physician was faxed, and no call was made to him. The DON acknowledged the resident had pain during the 02/19/2011 9:47 PM assessment. There was no documentation the physician was notified of Resident #5's pain until 02/20/2011 at 6:25 AM. At that time, Resident #5 was sent to the emergency room for evaluation. The facility's "Accident and Incident Report" policy, dated 10/02, indicated that staff should "provide any necessary emergency care" and "notify Charge Nurse, who then must notify Physician and Family." The facility's "Emergencies" policy, dated 12/03, stated, "emergency care procedure: 1. Nurse in charge of resident will evaluate resident's condition...A. Falls: 1. Check the resident immediately for ability to move extremities; check for bruised areas and/or cuts... 4. Check for any apparent dislocation or possible fracture. If any signs of this are noted, stabilize resident until ambulance arrives. 5. Exercise special care in transferring the resident, being careful not to do more damage. Immobilize with splint, if necessary. 6. Call resident's physician." Complaint #NV 257

Based on record review, policy review, and interview, the facility failed to ensure a resident was monitored and care provided to ensure the highest practicable physical well being for 1 of 4 residents (Resident #1). Findings include: Resident #1 Resident #1 was an [AGE] year old originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan indicated she was a high risk for pressure ulcers and listed approaches including: Pericare following each incontinent episode, turn & position every 2 hours, multipodus boot to left heel while in bed, skin prep to both heels every shift, pressure distribution devices to bed and wheelchair. Dietary measures were added which included vitamins and high protein supplements twice a day to promote wound healing. a) An event report dated 1/11/11 documented the resident developed a pressure sore on the left (L) heel, inner aspect with a blister 2.5 cm by 1.5 cm filled with fluid. Measures implemented including applying a protective boot, "floating" heel off bed and positioning resident to keep heel off bed. Documentation indicated the resident was monitored closely. The wound progressed to eschar which came off on 1/25/11. Underneath the skin was intact, and the wound healed. Documentation in the nurse's notes (NN) revealed the blister on the L heel remained and was being treated. On 3/7/11, the NN documented "wound has open draining area, reddness around edges, base shows dark necrotic tissue." Nurse's notes documented the L heel ulcer as below: - 3/08/11 - Stage II Pressure Ulcer to Lt lateral foot, previously noted as blister, measures 9 cm x 4.7 cm; - 3/18/11 - Blister to L heel has moderte dark yellow drainage with red border; - 3/21/11 - Old dressing cleaned - scant yellow exudate; - 3/23/11 - Small amount visible yellowish drainage - 3/28/11 - Blister on foot shows areas of slough and maceration... - 3/28/11 - A low grade temp 99.9 was reported - Tylenol given - 3/31/11 - small area of yellow slough tissue within wound There was no documented evidence the licensed nurse notified the physician of the drainage and slough noted from the heel ulcer. There was no documented evidence a wound culture was obtained to identify a possible source of infection and treatment with antibiotics, if indicated. The facility policy titled Protocol for Pressure Ulcer Prevention and Treatment dated 5/07 revealed: - " 7. When a resident is admitted to the facility or develops a pressure ulcer in the facility, the following will occur: - A. Assess the pressure ulcer(s) for location, size (measure length x width x depth), wound bed, drainage (amount, color, type), odor, tunneling, undermining or sinus tract, wound edges/surrounding tissue and pain at site ... " - " C. Notify the physician of above assessment and obtain orders for treatment of [REDACTED]. - " G. For pressure ulcers with drainage the physician will be notified and culture obtained if ordered ..." On 5/5/11 in the afternoon, the Director of Nursing indicated a wound culture was only obtained when ordered by the physician. Review of the pictures taken upon admission at the acute care facility on 4/12/11, revealed the resident's left foot wound was approximately 4 inches long with necrotic areas visible and purulent drainage on the wound and the dressing, which had been applied prior to admission. A wound culture was obtained on admission and the results showed the resident had - "Heavy growth of Coagulase Positive Staphylococcus -[MEDICAL CONDITION] ([MEDICAL CONDITION]." The resident was placed on contact precautions and started on IV antibiotics. b) The documentation in the Nurse's notes dated 2/17/11 revealed the resident was noted to have a reddened peri-rectal area, and faint pink rash along her left lateral thigh. Treatment included skin repair cream to groin with each cleansing There were no additional nurses notes reflecting the condition of the rash until 3/30/11. The nurses notes documented: - 3/30/11 - Patient has deep red excoriated rashing to entire perirectal area with open macerated appearance of tissue. Following cleansing in shower, topical antifungal cream applied to all areas, staff advised to stop multiple product use to evaluate area. - 3/30/11- Groin and perirectal area remains red with gaulded appearance and multiple open areas. - 4/1/11 - Perirectal area and medial thighs remain red with excoriated apearance. Stage II open area cleansed with all of involved area. - 4/7/11 - Inflammation of peri rectal area had markedly improved in past week. Open abraded appearance has resolved with exceptionof the right groin area which has dry scabbed appearance...Antifungal cream applied. The physician was not notified at the time the rash developed or when the condition of the rash had deteriorated to change the orders. The staff used "generic" antifungal cream without obtaining an order from the physician. The physician progress notes [REDACTED]." The physician progress notes [REDACTED]." On 5/5/11, the DON indicated there was no facility protocol specific to skin care and treatment of [REDACTED]. On 5/5/11 at 12:30 PM, an interview with the wound care nurse (WCN) revealed the resident had developed the Left lateral heel wound from rubbing her foot on the protective "boot" which had been placed on her left foot. The WCN added the resident had developed the rash in her perineal area due to her incontinence. There were no specific orders received for treatment of [REDACTED]. Each staff member was applying a different lotion to the area, depending on the staff''s preference including [MEDICATION NAME] and a "generic" antifungal cream supplied by the facility. The staff used the generic antifungal cream when they determined it was needed. The WCN verbalized using the generic antifungal was considered part of the standing orders. There was no physician's order for the antifungal cream. The WCN indicated on 3/30/11, she observed the change in the resident's perineal rash and instructed the staff to use only the one type of antifungal cream to evaluate if the rash would respond to that treatment. The nurse added she did not notify the physician of the change in the rash to obtain an order for [REDACTED]. Review of the pictures taken when the resident arrived at the acute care facility on 4/12/11, showed a very large excoriated area in the perineal and sacral area with multiple blisters and open areas. c) During the resident's admission from 1/11 through 2/11, the resident developed an upper respiratory infection (URI) which included symptoms of respiratory distress and an elevated temperature, and had been placed on antibiotics. The antibiotics were discontinued on 2/24/11. After that date, the resident developed a low grade temperature on several occasions including: 2/25 - temperature 101.7; 2/28 - 99.8; 3/17 - 99.2; 3/25 - 99.2; 3/27 - 99.2; 3/28 - 99.5; 4/7 - 99.2; 4/12 - 99.4. The resident received Tylenol on several occasions for the elevated temperature. There was no documented evidence the physician was notified of the elevated temperature so the resident could be evaluated for any underlying infections including wound infection, urinary tract infection or upper respiratory infection. d) The resident's medical history included a [DIAGNOSES REDACTED]. The physician's orders included an order for [REDACTED]. Date Blood Sugar - 2/07/11 264 - 2/14/11 284 - 2/21/11 290 - 2/28/11 250 - 3/07/11 210 - 3/14/11 180 - 3/21/11 164 - 3/28/11 190 - 4/04/11 192 - 4/11/11 208 (Normal range 70 - 115.) The physician's progress notes dated 12/29/10, 1/26/11 and 3/31/11 documented "The patient does have a significant history of diabetes currently on [MEDICATION NAME] 2.5 mg by mouth once daily. She seems to be tolerating this medication and her blood sugars have been stable." There was no documented evidence the facility monitored the resident's blood sugar more frequently than once per week, although the resident had signs of an infected wound and a low grade temperature on several occasions. There was no documented evidence the resident's medication was adjusted to maintain the resident's blood sugar within a normal range. Review of the acute care record for the admission of 4/12/11, revealed the resident's blood sugar upon admission to the ER was 989, a critically high value (Normal range 70 - 115). The resident was diagnosed with [REDACTED]. The resident was started on IV Insulin and antibiotics. Complaint #