Every finding on record at Las Vegas Post Acute & Rehabilitation

Based on observation, interview, record review, and document review, the facility failed to ensure informed consent for psychotropic medications was appropriately obtained and the purpose, risks, benefits, and potential side effects of the medications were explained to the resident for 1 of 29 sampled residents (Resident 98). The deficient practice had the potential to violate the resident's right to make informed decisions regarding treatment and to result in the administration of psychotropic medications without the resident's informed and voluntary, medication-specific consent. Findings include: Resident #98 (R98) was admitted on [DATE], with diagnoses including, anxiety disorder, bipolar disorder, and major depressive disorder. The Minimum Data Set, dated [DATE], documented the Brief Interview of Mental Status a score of 15/15, which meant R98's cognitive status was intact. The Comprehensive Resident admission dated 06/12/2026, documented R98 was alert and oriented to time, place, and person, able to follow simple commands, had a clear speech, make self-understood and had ability to understand others. A Physician Order dated 06/13/2026, documented Duloxetine Hydrochloride oral capsule 60 milligrams (mg) to give one capsule by mouth one time a day for depression. A Physician Order dated 06/13/2026, documented Buspirone Hydrochloride oral tablet 10 mg to give one tablet by mouth three times a day for anxiety manifested by inability to relax. A Physician Order dated 06/15/2026, documented Mirtazapine 0ral tablet 15 mg to give one tablet by mouth at bedtime for depression. A Physician Order dated 06/17/2026, documented Divalproex Sodium tablet delayed release 250 mg to give one tablet by mouth two times a day for mood disorder manifested by mood swings. The Medication Administration Record for June 2026 documented the psychotropics medications such as Duloxetine, Buspirone, Mirtazapine and Divalproex Sodium were successfully administered to R98 as ordered. The Informed Consent forms dated 06/12/2026, revealed that R98's signature, the nurse's signature, and the date of signature appeared to be photocopied on each form. The only information that appeared to have been individually completed on each form was the name of the psychotropic medication for Duloxetine, Trazodone, Buspirone, and Mirtazapine. On 06/24/2026 in the afternoon, R98 recounted that the only psychotropic medication for which informed consent had been provided was Depakote (Divalproex Sodium) and that only one informed consent form had been signed. When presented with the informed consent forms for the other psychotropic medications, R98 stated that the signatures were not R98's original signatures. R98 indicated an informed consent had not been provided for the other psychotropic medications because R98 did not want to take multiple psychotropic medications and had only agreed to take Depakote. R98 indicated that photocopying R98's signature onto informed consent forms was not appropriate. On 06/24/2026, at 4:45 PM, a Licensed Practical Nurse (LPN) confirmed having photocopied a previously signed psychotropic medication informed consent form and documented different psychotropic medications on the copied forms. The LPN indicated the intent had been to duplicate the form and acknowledged not recognizing the resident's original signature, the nurse's signature, and the date of signature had also been duplicated. The LPN acknowledged the discussion with R98 generally focused on the physician's order and whether the residents agreed to take the medication. The LPN acknowledged the purpose, risks, benefits, and potential side effects of each psychotropic medication had not been explained prior to obtaining consent. On 06/25/2026 at 8:15 AM, verification of the original informed consent forms was conducted with the Medical Records Staff, and the Director of Nursing (DON). Both confirmed the original informed consent forms contained a photocopied R98 signature, the LPN's signature, and the date at the bottom of the forms. The only handwritten entry on each form was the medication name in the designated section. The DON indicated the risks, benefits, and purpose of each psychotropic medication should have been explained to the resident before informed consent was obtained. The DON explained each psychotropic medication should have been signed and required a separately executed original informed consent form to document the resident's informed agreement to receive the medication. On 06/25/2026 at 9:50 AM, the Psychiatrist explained the process for prescribing psychotropic medications included assessing the resident's symptoms, determining whether medication was clinically indicated, discussing previous medication use, and explaining the purpose, risks, benefits, alternatives, including the option of declining treatment, and potential side effects of the medication. The Psychiatrist indicated residents were asked whether they were willing to start, change, or discontinue medication, and verbal consent was obtained during the discussion. The Psychiatrist indicated unawareness that the facility required written informed consent before psychotropic medications and indicated no prior knowledge of the circumstance the LPN photocopied R98's signature. A facility policy titled, Psychotropic Drug Treatment, revised 12/2016, documented the residents or their representatives were to be provided with information regarding the need for the medication, its intended effects, and its potential side effects to enable them to make an informed decision regarding the use of psychotropic medications. The policy further indicated residents and their representatives were to be involved in the medication management process and informed of the benefits, risks, and goals of psychotropic medication treatment. A facility policy titled, Consent revised 11/2020, documented in adherence with resident's bill of rights, facility would obtain consent, whereby applicable and indicated, from resident and or responsible party, and or family member for administration of treatment and or procedure. Informed Consent means the voluntary agreement of a resident to receive an identified treatment or procedure.

Based on observation, interview, record review, and document review, the facility failed to ensure specialized services were provided as specified on Pre-admission Screening and Resident Review (PASRR) level II for 1 of 29 sampled residents (Resident R7). The deficient practice had the potential to delay the resident's access to clinically necessary psychotherapy services, hinder appropriate transition planning to a less restrictive environment, and result in inadequate monitoring and advocacy. This placed the R7 at risk for unmet clinical, functional, and psychosocial needs.Findings include: Resident 7 (R7) was admitted on [DATE] with diagnoses of including paranoid schizophrenia, schizophrenia, post traumatic stress disorder (PTSD), and chronic medical conditions. According to the physician's orders, the resident received risperidone for schizophrenia and bipolar disorder, mirtazapine for depression with anxiety, and prazosin for symptoms related to PTSD. R7 had a Nevada PASRR Level II evaluation completed on 05/26/2026. The evaluation indicated Placement Option II B, confirming resident met the nursing facility level of service and could be admitted if the facility was able to provide the recommended specialized services. The Specialized Services Determination identified the need for individual, group, and/or family psychotherapy; psychiatrist follow up services; monitoring and advocacy; and transition services to support movement to a less restrictive environment. The medical record lacked documented evidence psychotherapy progress notes had been completed for the resident. A Social Services progress note dated 04/27/2026 documented the resident had requested assistance in identifying appropriate placement. However, there was no evidence the facility had initiated or completed any actions related to transition services, nor was there documentation the facility was actively seeking or coordinating services to assist the resident in transitioning to a less restrictive environment. On 06/25/2026 at 3:00 PM, the Director of Social Services, explained when a resident had a PASRR Level II determination, the resident was required to receive specialized services such as individual, group, and/or family psychotherapy; psychiatrist follow-up services; monitoring and advocacy; and transition services to assist the resident in moving to a less restrictive environment. The Director of Social Services acknowledged there was no documentation indicating the resident had been receiving individual, group, and/or family psychotherapy. The Director of Social Services indicated the resident had requested assistance with placement should have been receiving psychotherapy services. On 06/25/2026 at 3:23 PM, R7 verbalized staff only checked to ask how they were doing, but the facility had not offered any individual, group, or family psychotherapy services. R7 reported having requested assistance in obtaining an appropriate placement, yet no one had discussed any placement options. R7 explained requesting for placement during the first two weeks of stay at the facility; however, no follow-up occurred. A review of the psychosocial assessment revealed a clinical recommendation documented R7 would benefit from continued individual psychotherapy. This recommendation was made to address ongoing psychotic symptoms, mood instability, and adjustment difficulties, as well as to support the development of healthy coping strategies. A review of the physician progress notes for June 2026 documented R7 should be encouraged to participate in groups and other activities within the therapeutic milieu structured, supportive, and safe environment designed to promote healing, emotional wellbeing, and positive behavioral change for individuals receiving care often in mental health, rehabilitation, or long-term care settings. The medical records lacked documented evidence the resident was receiving individual, group and/or family psychotherapy. The psychiatric progress note dated 06/04/2026, documented R7 was evaluated for follow-up regarding psychotropic medication management. R7 was observed pacing the unit and speaking to himself at length. Nursing staff reported this behavior had been ongoing; however, they noted no significant behavioral concerns. The resident was observed responding to internal stimuli. R7's ability to engage in conversation was limited due to distractibility, but R7 was agreeable to increasing the dose of Risperdal to 2 milligrams (mg) by mouth (PO) twice a day (BID). The risks, benefits, and alternatives were discussed. R7 denied suicidal ideation, homicidal ideation, and auditory or visual hallucinations. The facility's policy and procedure titled Pre-admission Screening and Resident Review level II, dated September 2020, documented resident who have either a mental illness, intellectual disability or related condition meets criteria for Level II PASRR and are eligible for admission to a nursing facility will be provided with specialized services to manage mental illness, intellectual disability or related condition.

Based on observation, interview, record review, and document review, the facility failed to ensure informed consent for psychotropic medications was obtained in accordance for 1 of 29 sampled residents (Resident 98) with accepted professional standards of practice, as evidenced by the use of photocopied informed consent forms. The deficient practice had the potential to result in the administration of psychotropic medications without valid, voluntary, medication-specific informed consent, to misrepresent the resident's authorization for treatment, and to compromise the authenticity and reliability of the medical record. Findings include:Resident #98 (R98) was admitted on [DATE], with diagnoses including, anxiety disorder, bipolar disorder, and major depressive disorder. The Minimum Data Set, dated [DATE], documented the Brief Interview of Mental Status a score of 15/15, which mean R98's cognitive status was intact. A Physician Order dated 06/13/2026, documented Duloxetine Hydrochloride oral capsule 60 milligrams (mg) to give one capsule by mouth one time a day for depression. A Physician Order dated 06/13/2026, documented Buspirone Hydrochloride oral tablet 10 mg to give one tablet by mouth three times a day for anxiety manifested by inability to relax. A Physician Order dated 06/15/2026, documented Mirtazapine 0ral tablet 15 mg to give one tablet by mouth at bedtime for depression. A Physician Order dated 06/17/2026, documented Divalproex Sodium tablet delayed release 250 mg to give one tablet by mouth two times a day for mood disorder manifested by mood swings. The Medication Administration Record documented the psychotropics medications such as Duloxetine, Buspirone, Mirtazapine and Divalproex Sodium were successfully administered to R98 as ordered. The Informed Consent forms dated 06/12/2026, revealed that R98's signature, the nurse's signature, and the date of signature appeared to be photocopied on each form. The only information that appeared to have been individually completed on each form was the name of the psychotropic medication for Duloxetine, Trazodone, Buspirone, and Mirtazapine. On 06/24/2026, in the afternoon, R98 recounted that the only psychotropic medication for which informed consent had been provided was Depakote (Divalproex Sodium) and that only one form had been signed. R98 further indicated that informed consent had not been provided for the other psychotropic medications because R98 did not want to take multiple psychotropic medications and had only agreed to take Depakote. R98 indicated that photocopying R98's signature onto informed consent forms was not appropriate. On 06/25/2026 at 8:15 AM, verification of the original informed consent forms was conducted with the Medical Records Staff, and the Director of Nursing (DON). Both confirmed the original informed consent forms contained a photocopied R98 signature, the LPN's signature, and the date at the bottom of the forms. The only handwritten entry on each form was the medication name in the designated section. The DON indicated the risks, benefits, and purpose of each psychotropic medication should have been explained to the resident before informed consent was obtained. The DON explained each psychotropic medication required a separately executed original informed consent form to document the resident's informed agreement to receive the medication. The DON indicated photocopying a resident's signature on informed consent forms was not the facility's standard of practice and expressed each informed consent should have been completed with original signatures for each medication. On 06/25/2026, at 4:45 PM, a Licensed Practical Nurse (LPN) confirmed having photocopied a previously signed psychotropic medication informed consent form and documented different psychotropic medications on the copied forms. The LPN stated the intent had been to duplicate the form and acknowledged not recognizing that the resident's original signature, the nurse's signature, and the date of signature had also been duplicated. The LPN acknowledged that the discussion with R98 generally focused on the physician's order and whether R98 agreed to take the medication. The LPN acknowledged that R98 had consented to only one psychotropic medication, Depakote (Divalproex Sodium), and that the purpose, risks, benefits, potential side effects, and alternatives of each psychotropic medication had not been explained prior to obtaining informed consent. The LPN acknowledged that photocopying a resident's signed informed consent form for use with additional psychotropic medications was inappropriate and not in accordance with accepted standards of nursing practice because it did not demonstrate that the resident had received medication-specific information or had voluntarily consented to each medication individually. On 06/25/2026 at 9:50 AM, the Psychiatrist indicated being unaware of the facility's requirement to obtain written informed consent for psychotropic medications and stated having no prior knowledge that photocopied informed consent forms containing duplicated signatures had been used. On 06/25/2026 at 12:10 PM, the Nurse Practitioner (NP) indicated that informed consent should be obtained individually for each psychotropic medication after explaining the medication's purpose, risks, benefits, and potential side effects to the resident or the resident's responsible party. The NP acknowledged that photocopying a previously signed consent form and reusing the R98's signature, the nurse's signature, and the date of signature for additional psychotropic medications was inappropriate. The NP indicated that failure to obtain original informed consent for each psychotropic medication and failure to explain the purpose, risks, benefits, and potential side effects prior to obtaining consent did not meet the standard of care and professional practice. A facility policy titled, Psychotropic Drug Treatment revised 12/2016, the residents or their representatives were to be provided with information regarding the need for the medication, its intended effects, and its potential side effects to enable them to make an informed decision regarding the use of psychotropic medications. The policy further indicated residents and their representatives were to be involved in the medication management process and informed of the benefits, risks, and goals of psychotropic medication treatment. A facility policy titled, Consent revised 11/2020, documented in adherence with resident's bill of rights, facility would obtain consent, whereby applicable and indicated, from resident and or responsible party, and or family member for administration of treatment and or procedure. Informed Consent means the voluntary agreement of a resident to receive an identified treatment or procedure.

Based on observation, interview, record review, and document review, the facility failed to ensure the resident received the required podiatry services for 1 of 29 sampled residents (Resident R70). This deficient practice had the potential to result in skin breakdown, infection, and amputation.Findings include: Resident 70 (R70) was admitted on [DATE] with diagnoses including atherosclerotic heart disease of the native coronary artery without angina pectoris, polyarthritis, type 2 diabetes mellitus with hyperglycemia, psoriasis, and dementia. A physician order dated 4/6/2026, revealed podiatry care was to be provided every two months and as needed for the treatment of mycotic and hypertrophic nails, corns, and calluses. On 06/23/2026 at 10:31 AM, a Certified Nursing Assistant (CNAs) verbalized they could not cut or trim the resident's fingernails or toenails because the resident was diabetic. The CNA explained CNAs were not permitted to perform nail care on diabetic residents due to the increased risk of injury and infection. The CNA emphasized the nurse would be informed so the appropriate follow up could occur. On 06/26/2026 at 8:17 AM, the Director of Social Services explained when a resident was diabetic, CNAs did not trim the resident's fingernails or toenails; those services were provided entirely by the podiatrist. The Director of Social Services indicated there was a standard physician order for podiatry services for all residents upon admission. The Director of Social Services acknowledged there was no care plan or progress note in place regarding podiatry services. The Director of Social Services noted the Social Services Assistant was responsible for scheduling the podiatry appointments. On 06/26/2026 8:31 AM, the Director of Nursing (DON) indicated all residents during admission had a standard Physician Order for podiatry services. The DON indicated the Social Services department scheduled the residents for podiatry services,and the nursing staff would generate the care plans and progress notes. The DON indicated the Social Services provided a list of residents needing podiatry services to the Podiatrist. On 06/26/2026 at 8:37 AM, the Social Services Assistant indicated the podiatry schedule was created when the nurses or therapy staff informed Social Services a resident required podiatry services. Once notified, the Social Services Assistant generated the list for the podiatrist, usually twice a month. The Social Services Assistant stated the podiatrist also would come to the facility if there was an emergency need. The Social Services Assistant reported R70 was admitted on [DATE]. The Social Services Assistant was unable to send the resident face sheet for podiatry services on 04/17/2026. On 04/23/2026, a question mark appeared next to R70's name on the podiatry list. The Social Services Assistant indicated they did not know why the question mark was placed there. The Social Services Assistant acknowledged R70 did not receive podiatry services and confirmed the resident did not receive podiatry care in May 2026. On 06/26/2026 at 10:33 AM, the Assistant Director of Nursing (ADON) indicated a head-to-toe assessment was completed by the nurse upon a resident's admission. The ADON explained the wound care nurse then performed a more comprehensive skin assessment the following day to ensure there was no skin breakdown. ADON acknowledged the skin assessment for R70 should have included an evaluation of both the fingernails and toenails to ensure there was no discoloration, especially given that the resident was diabetic. On 06/26/2026 at 11:40 AM, the Wound Care Nurse explained a skin assessment was performed from head to toe upon a resident's admission to ensure there were no skin issues requiring attention. The Wound Care Nurse explained the skin assessment should have included in examining the resident's fingernails and toenails. The Wound Care Nurse indicated the facility had a standard physician order for podiatry services. The Wound Care Nurse further stated when a new resident was admitted , the Social Services Department immediately placed the resident on the podiatry list to ensure the resident would be seen. On 06/26/2026, the podiatrist's email documented the question mark placed next to the R70's name on 04/23/2026 indicated the nursing staff was providing care for R70. The podiatry team had intended to provide services but was ultimately unable to do so. The facility's policy titled podiatry services dated December 2016 stated podiatry services are available to meet the resident's podiatry needs in accordance with the resident's assessment and plan of care.

Based on record review, interviews, observations, and document review, the facility failed to ensure that weights were obtained and documented accurately for 3 of 29 sampled residents (Residents 2, 10, and 44). The deficient practice had the potential to affect accurate monitoring of residents' nutritional status and delay interventions necessary to prevent avoidable decline. Findings include: Resident 2 (R2) was admitted on [DATE] with diagnoses including protein calorie malnutrition, hypokalemia, aggressive outbursts, anxiety, and dementia. R2's weight records documented the following weights: 04/01/2026: 96.6 lbs. R2 was hospitalized on [DATE] following a hip fracture sustained during a fall and was re-admitted to the facility on [DATE]. 05/09/2026: 87.2 pounds (lbs.). 05/13/2026: 87.2 lbs. 05/25/2026: 89.4 lbs. 06/01/2026: 83.4 lbs. 06/08/2026: 80.2 lbs. There was a significant weight loss of 8% over 30 days, starting on 05/09/2026. 06/15/2026: 78.8 lbs. There was a significant weight loss of 10.47% over 37 days, starting on 05/09/2026. The medical record lacked documentation that R2's weight was obtained at admission and weekly for 4 weeks, as weights were not recorded for the week between 05/17/2026 and 05/23/2026. The weights were not re-taken to rule out the possibility that the significant weight variance was due to measurement error. A nutritional assessment dated [DATE] indicated R2 was evaluated following re admission with documented diagnoses including protein calorie malnutrition and hypokalemia. The assessment showed a calculated body mass index (BMI) of 18.7, and the resident remained at risk for malnutrition as evidenced by a Mini Nutritional Assessment (MNA) score of 7. The care plan interventions included monitoring and documenting weekly weights for four weeks. Nutritional care plan dated 05/13/2026 documented R2 was identified as having potential for unintended weight loss and was considered at risk for malnutrition related to Alzheimer's disease/dementia, chronic illness, cognitive impairment, decreased appetite, depression, and increased nutritional needs for wound healing. Interventions included weighing the resident according to facility protocol. A weight variance review dated 06/23/2026, revealed R2 weight obtained on 06/15/2026 was 78.8 lbs. and the height obtained on 01/23/2026 was 57 inches. The review documented a BMI 19.3 (healthy weight) but based on the weight and height, the calculated BMI should have been 17.1 Mini nutritional assessment dated [DATE] scored 7.0, indicating R2's nutritional status was malnourished. On 06/24/2026 at 2:10 PM, the Director of Nursing (DON) explained that resident's weight should have been obtained on admission, weekly for 4 weeks then monthly. If variances were significant, the weight should have been verified to confirm the variance was accurate. DON acknowledged R2 experienced variances on weight that were not verified. Resident 10 (R10) was admitted on [DATE], with diagnoses including protein malnutrition, dysphagia, dehydration, acute kidney injury, hyperkalemia, dementia, gastrostomy tube. R10's weight records revealed that from January through June 2026, the resident's recorded weights documented the following weights: 01/01/2026: 114.6 lbs. 02/02/2026: 119.8 lbs. 03/02/2026: 114.2 lbs. 04/01/2026: 118.2 lbs. 04/13/2026: 115.0 lbs. 06/01/2026: 107.8 lbs., (marked as incorrect documentation) 05/02/2026: 110.2 lbs., (marked as incorrect documentation) 06/24/2026: 113.8 lbs. The medical record lacked documented evidence weight was obtained monthly from 04/14/2026 through 06/24/2026. The medical record documented R10 was transferred to a hospital on [DATE] due to decline in health condition and was re-admitted on [DATE] with a gastrostomy tube. The record revealed a weight was recorded on 04/01/2026 while the resident was absent from the facility. The record lacked documented evidence weights were obtained upon admission on [DATE]. On 06/25/2026 at 11:00 AM, the kitchen manager, who was assigned to obtain and document weights in the medical record, stated the dates entered in the weight records reflected the dates the weights were charted rather than the dates the weights were actually obtained. The kitchen manager acknowledged being unaware that the required practice was to document the date the weight was obtained. On 06/25/2026 at 11:15 AM, the Registered Dietitian (RD) stated weights documented in the medical record must be accurate since many resident care decisions, including calorie and nutrition planning, depend on current weight. The RD emphasized accurate weights were critical for residents at risk for malnutrition. Resident 44 (R44) was admitted on [DATE], with diagnoses including type 2 diabetes mellitus and hypertension. Weight record documented the following weight: 02/28/2026: 115.0 lbs. 03/09/2026: 115.8 lbs. 03/16/2026: 115.4 lbs. 03/23/2026: 115.6 lbs. 04/01/2026: 117.6 lbs. 04/13/2026: 108.4 lbs. There was a significant weight loss of 7.35% over 12 days, starting on 04/01/2026, and 6% over 28 days, starting on 03/16/2026. 06/23/2026: 150.0 lbs. There was a significant weight gain of 38.37% over 71 days, starting on 04/13/2026. R44's medical record contained no evidence the significant weight fluctuations were rechecked to verify accuracy, and no weight was documented for May 2026. On 06/25/2026 at 2:00 PM, R44 was reweighed by the DON using the same scale. The weight obtained was 145 lbs. with the wheelchair. After removing the wheelchair weight (39.6 lbs.), the remaining weight was 105.4 Lbs. On 06/25/2026 at 2:00 PM, the RD confirmed the recorded weight was an error and agreed it should have been verified to identify the discrepancy. The facility policy titled Weight Variance Committee, last revised in April 2017, documented the Weight Variance Committee (WVC) would identify residents with significant weight changes, place them on weight-variance monitoring, and meet weekly and as needed. The policy indicated significant weight changes were identified as follows: 1 week; 2% weight loss or gain was significant 1 month: 3% weight loss or gain for residents equal to or less than 100 lbs. was significant. 1 month: 5% or 5 lbs. weight loss or gain was significant. 3 months - 7.5% weight loss or gain was significant. 6 months - 10% weight loss or gain was significant. The medical record lacked documented evidence the WVC addressed the weight variances documented in the medical record of Residents 2, 10, and 44. The facility policy titled Weight Assessment and Interventions, revised in September 2008, indicated weights were to be obtained on admission and measured weekly for four weeks, then measured monthly if no concerns were identified. Weights were to be recorded in each unit's weight record and in the resident's medical record. The Interdisciplinary Team (IDT) was required to meet monthly to review recorded weights, significant weight changes, and overall trends.

Based on observation, interview, record review, and document review, the facility failed to ensure the administered resident's enteral feeding formula was labeled as ordered and physician orders for percutaneous endoscopic gastrostomy (PEG) tube care and monitoring were obtained, transcribed, and implemented in a timely manner for 1 of 29 sampled residents (Resident 99).The deficient practice had the potential to result in delayed or inappropriate treatment, inaccurate or missed monitoring of the resident's PEG tube insertion site, administration errors, compromised nutritional status, and adverse health outcome. Findings include: Resident 99 (R99) was admitted on [DATE], and readmitted on [DATE], with diagnoses including failure to thrive, dementia, and dysphagia (difficulty swallowing). On 06/23/2026 at 12:25 PM, R99 was lying in bed with eyes closed. R99's enteral feeding Nepro 1.8 (1,000 milliliter [mL] bottle) was observed infusing at 50 mL per hour. The tube feeding formula container was observed without a label indicating the resident's name, room number, date, start time (AM/PM), and formula rate. A physician order dated 06/22/2026, documented nothing by mouth (NPO) for diet, texture, and consistency. A physician order dated 06/22/2026, documented to label the formula container, syringe, and administration set with the resident's name, date, time, and nurse's initials every night shift. R99's medical record lacked documented evidence physician orders for percutaneous endoscopic gastrostomy (PEG) tube care and insertion site monitoring and PEG tube dressing changes, had been obtained timely and transcribed into the electronic medical record. A physician order dated 06/23/2026, documented enteral Nutrition via pump: Nepro at 56 milliliters/hour (ml/hr) times 20 hours, or until dose is completed to provide 2016 ml kilocalories. On 06/24/2026 at 10:00 AM, the Director of Nursing (DON) indicated that upon a resident's admission with enteral feeding, a comprehensive assessment should have been completed, and physician orders should have been obtained for the enteral feeding infusion rate, water flushes, PEG tube site monitoring and dressing changes. The DON confirmed physician orders for the enteral feeding regimen, including water flushes, had not been obtained and transcribed timely. The DON confirmed there was no documented evidence that physician orders had been obtained for monitoring the PEG tube insertion site or for PEG tube dressing changes. The DON indicated the admitting nurse, or the assigned floor nurse was responsible for ensuring all required physician orders, assessments, and care interventions were implemented to ensure safe and continuous care. The DON acknowledged these requirements had not been completed within 24 hours of the resident's admission. On 06/25/2026 at 12:10 PM, the Nurse Practitioner (NP) revealed residents admitted with a PEG tube were expected to receive a comprehensive admission assessment. The NP explained the admitting nurse was expected to assess and document the condition of the PEG tube insertion site, upon resident's admission to establish a baseline for care. The NP indicated physician orders for the enteral feeding regimen, including the formula, infusion rate, flushing instructions, and PEG site care and management, The NP indicated the TF orders should have been transcribed in the electronic records and implemented upon admission. The NP explained the enteral feeding formula bag and administration tubing should have been labeled with the resident's name, formula, date, time, initials, and infusion rate to ensure continuity of care and safe administration. The NP explained dietary and other applicable consultants should have been notified upon admission as appropriate. A facility policy titled Enteral Feeding Tube Care, dated 10/2014, documented that the facility would provide care and services to residents receiving nutrition via an enteral feeding tube to prevent irritation and skin breakdown around the feeding tube insertion site, prevent odor, and promote resident comfort. The policy directed staff to assess the condition of the skin surrounding the tube insertion site, noting the presence of skin irritation, drainage, or foul odor. The policy further directed staff to cleanse the skin around the feeding tube with normal saline, pat the area dry, apply a drain sponge dressing at the tube insertion site, and document the assessment findings and physician orders. A facility policy titled Physician Orders, dated 12/2025, documented the facility would provide care and services to residents in accordance with physician orders.

Based on observation, interview, record review, and document review, the facility failed to ensure physician orders for a resident requiring continuous oxygen therapy were followed 1of 29 sampled residents (Resident R11). This deficient practice had the potential for residents to be at risk of hypoxemia, cardiac strain or respiratory failure.Findings include: Resident 11(R11) was admitted to the facility on [DATE] with diagnoses including influenza, unspecified pneumonia, encephalopathy, acute respiratory failure with hypoxia, schizophrenia, and recurrent major depressive disorder. On 06/23/2026 at 2:39 PM, during an observation, the resident's oxygen nasal cannula was not in place. The resident had a portable oxygen tank on the wheelchair, but the oxygen was not applied. In addition, the oxygen concentrator located at the bedside was also not connected to the resident. A physician order dated 01/30/2026, documented the resident was to receive oxygen at a continuous flow rate of 2 liters per minute via nasal cannula. The order directed staff to provide supplemental oxygen continuously, ensuring uninterrupted administration throughout the resident's care. The oxygen was prescribed to manage the resident's shortness of breath. On 06/24/2026 at 12:29 PM, the Registered Nurse (RN) indicated nursing staff were required to ensure the resident had the nasal cannula in place. The RN explained when a nurse observed the resident without the nasal cannula, it should be immediately reapplied. The RN indicated if the resident was not wearing the nasal cannula, it could decrease the resident's oxygenation. The RN added if CNAs noticed the resident without the nasal cannula, they were to notify the nurse immediately and assist with putting it back on the resident. The RN acknowledged the resident remained on continuous oxygen per the physician's order and therefore should have oxygen in place. On 06/24/2026 at 1:20 PM, the Director of Nursing (DON), indicated when a resident was ordered to receive continuous oxygen, the nursing staff were responsible for ensuring the nasal cannula remained in place, in accordance with the physician's order. The DON acknowledged if a resident wished to be weaned off oxygen, the nurse was required to notify the physician and obtain a new order before making any changes. On 06/24/2026 at 1:54 PM, R11 indicated used oxygen because experienced shortness of breath and reported needed oxygen due to a history of smoking. On 06/24/2026 at 3:31 PM, R11 was observed sitting in a wheelchair in the activities room without the nasal cannula in place. The portable oxygen tank was present and was not empty, yet the oxygen was not being applied to the residents. A review of R11's care plan revealed the resident was identified as being at risk for respiratory distress related to COPD and respiratory failure. The care plan goal documented the resident would maintain effective airway clearance daily for 90 days. The care plan interventions/tasks indicated staff were to assess the resident's respiratory status every shift and to promptly notify the attending physician of any changes. The care plan documented use oxygen as ordered. The facility's policy and procedure titled Oxygen Therapy, dated January 2019, documented oxygen therapy was to be administered as ordered by the physician. The facility's policy and procedure titled Physician Orders, dated December 2025, documented it was the facility's policy to provide care and services to residents in accordance with physician orders.

Based on observation, interview, record review, and document review, the facility failed to ensure: 1) appropriate resident placement by cohorting a resident with invasive devices, including an indwelling urinary catheter and a gastrostomy feeding tube, with a resident who was infected or colonized with a multidrug-resistant organism (MDRO) for 1 of 29 sampled residents (R99), and 2) staff properly followed personal protective equipment (PPE) requirements. The deficient practice had the potential to result in the transmission of infectious organisms, including multidrug-resistant organisms, and placed residents at increased risk for infection and adverse health outcomes.Findings include:1) Appropriate Placement Resident 98 (R98) was admitted on [DATE], with diagnoses including acute left ankle and foot osteomyelitis, type 2 diabetes mellitus with foot ulcer and methicillin-resistant Staphylococcus aureus (MRSA). A Physician order dated 06/12/2026, documented contact isolation precaution: MRSA in R98's great toe. On 06/23/2026 at 12:15 PM, contact isolation signage was posted on R98's door in room [ROOM NUMBER], and a personal protective equipment (PPE) supply bin stocked with appropriate PPE was observed outside the room. R98 indicated admission to the facility on [DATE] following hospitalization for a left toe amputation secondary to diabetes mellitus. R98 indicated the wound had been tested positive for MRSA and contact isolation precautions had been implemented for the wound. Resident 99 (R99) was admitted on [DATE], and readmitted on [DATE], with diagnoses including failure to thrive, dementia, and dysphagia (difficulty swallowing). A Physician Order dated 06/22/2026, documented enhanced barrier-precautions On 06/23/2026 at 12:25 PM, contact isolation signage posted on R99's door. R99 was lying in bed with eyes closed in room [ROOM NUMBER] bed A. R99's enteral feeding was observed to be infusing at 50 mL per hour. A Foley catheter was in place and draining approximately 200 mL of yellow urine into the collection bag. On 06/23/2026 in the afternoon, R99 remained in room [ROOM NUMBER]. The enteral feeding was observed to be infusing, and the indwelling Foley catheter was observed draining yellow urine. On 06/23/2026 in the morning, a Registered Nurse confirmed had PEG tube and Foley catheter and should have been in Enhanced Barrier Precautions (EBP). The RN indicated that R99 had no active infections. On 06/24/2026 at 8:20 AM, the Assistant Director of Nursing (ADON) confirmed that R99 had been placed in room [ROOM NUMBER] with R98, who was on contact isolation for a methicillin-resistant Staphylococcus aureus (MRSA)-positive wound. The ADON indicated that the admitting nurse had assigned R99 to room [ROOM NUMBER] despite the room being designated for contact isolation precautions. The ADON indicated that R99 should not have been placed with R98 because R99 had a percutaneous endoscopic gastrostomy (PEG) tube and an indwelling Foley catheter, which placed R99 at increased risk for infection due to the presence of invasive devices. On 06/24/2026 at 8:22 AM, the Director of Nursing (DON) confirmed R99 was placed with R98, who had an active MRSA-positive wound and was on contact isolation. The DON indicated it was not good infection prevention practice to cohort R99 with a resident who had an active infection. The DON indicated R99 had no active infection, had a PEG tube and an indwelling Foley catheter, both of which created openings in the body and placed R99 at increased risk for infection. The DON indicated once the inappropriate placement was identified, R99 was transferred to another room and placed on EBP. On 06/24/2026 at 9:10 AM, an interview with the Infection Preventionist (IP) revealed R99 should not have been cohorted with R98, who had an active MRSA-positive wound. The IP indicated residents with invasive devices or skin openings, including a PEG tube and an indwelling Foley catheter, were at increased risk for acquiring infection because the normal protective skin barrier had been compromised. The IP indicated R99 should not have been cohorted with R98 even if the MRSA-positive wound had been contained with a dressing, as the presence of an active infection continued to pose an infection transmission risk and appropriate resident placement should have been maintained. On 06/25/2026 at 12:10 PM, the Nurse Practitioner indicated residents with PEG tube and an indwelling Foley catheter were at increased risk for healthcare-associated infections because of the presence of invasive devices and required ongoing assessment and monitoring for signs and symptoms of infection. The NP indicated it was inappropriate to cohort the resident with invasive devices to a resident with active infection like MRSA-wound even if they were contained. A facility policy titled, Room Placement, revised 01/2012, indicated the facility would provide appropriate room placement for residents infected or colonized with multidrug-resistant organisms (MDROs). The policy further indicated that a resident with an MDRO might have required separation from a roommate who had an invasive device, such as an indwelling urinary catheter, gastrostomy feeding tube, or intravenous access line, or who had a pressure ulcer or other open skin wound, including a postoperative wound. 2) Personal Protective Equipment (PPE) Requirements On 06/25/2026 at 1:45 PM, a Hospitality Aide was observed passing ice water from room to room. room [ROOM NUMBER] had Contact Precautions signage posted at the room doorway directing staff and visitors to perform hand hygiene and don a gown and gloves upon entry. The Hospitality Aide entered room [ROOM NUMBER] without performing hand hygiene or donning the required personal protective equipment (PPE). The Hospitality Aide delivered a water pitcher to Resident 98 (R98) and removed the resident's lunch tray before exiting the room. The Hospitality Aide acknowledged the required personal protective equipment (PPE), including a gown and gloves, should have been donned before entering the room but had not been worn. The Hospitality Aide explained that assigned responsibilities included assisting Certified Nursing Assistants with repositioning residents and performing other tasks, including passing and collecting water pitchers and meal trays. The Hospitality Aide was unable to differentiate between Contact Precautions from EBP and initially indicated that PPE should have been worn upon entering rooms under both precaution categories to protect staff and residents. The surveyor provided education regarding the differences between Contact Precautions and Enhanced Barrier Precautions and the appropriate use of PPE for each precaution category. On 06/24/2026 at 1:45 PM, an interview with a Housekeeper revealed assigned responsibilities included cleaning resident rooms and bathrooms and, at times, assisting staff with environmental care activities. The Housekeeper indicated Contact Precautions residents with active infections and required the use of personal protective equipment (PPE), including a gown, gloves, and mask, to protect staff and residents. When asked to differentiate Contact Precautions from Enhanced Barrier Precautions (EBP), the Housekeeper initially indicated that the same PPE requirements applied when entering rooms under both Contact Precautions and Enhanced Barrier Precautions. The Housekeeper was unable to accurately distinguish the differences between the two transmission-based precautions. The surveyor provided education. A facility policy titled Isolation - Initiating Transmission-Based Precautions (undated), indicated required staff entering a resident's room under Contact Precautions to don the appropriate personal protective equipment (PPE), including a gown and gloves, prior to room entry, and to follow the posted precaution signage.

Based on observation, interview, record review, and document review, the facility failed to ensure a vulnerable resident was protected following physical abuse allegation for 1 of 4 sampled residents (R1). The deficient practice had the potential to result in increased fear, anxiety, emotional distress, and an increased risk of psychosocial harm.Findings include:Resident 1 (R1) was admitted on [DATE], with diagnoses including difficulty in walking and generalized muscle weakness.The admission Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status score of 15 out of 15, indicating R1's cognitive status was intact. The assessment documented that R1 required extensive assistance with activities of daily living and was dependent on staff for transfers and incontinent care.The Nursing Staff Assignment and Sign in Sheet dated 06/01/2026, documented the involved CNA was assigned in room [ROOM NUMBER]A wherein R1was residing in 101.A typewritten statement by Social Services Assistant (SSA) dated 06/03/2026, documented that the SSA was notified that R1 was concerned about the involved CNA being in their room and assigned to R1's roommate.On 06/10/2026 at 11:45 AM, R1 was alert, oriented, verbally responsive, and remained in-house. R1 expressed frustration when the involved CNA from a recent physical abuse incident entered R1's room after R1 had been assured that the involved CNA would no longer provide care or enter the room. R1 reported on 05/02/2026, during incontinent care, the involved CNA jabbed the resident in the buttocks area three times. R1 explained, There is a difference between wiping you and jabbing you. R1 reported feeling terrible following the incident and stated, It was not by accident. R1 also reported another incident during care in which R1 felt something poke the leg and stated, I said, oh, something stuck me. According to R1, the involved CNA responded, That's your imagination.R1 reported that after being informed the CNA would no longer come near the resident or enter the room, the CNA was later assigned to the roommate in the same room. R1 stated, I was promised that (name) would not come anywhere near me again, would not come in the room again. But last week, she did. She came in the room at night. R1 reported repeatedly asking, Who are you? What do you want? and stated that the individual did not respond. R1 stated, I got scared, with somebody coming in, and I screamed for help. R1 reported that the individual left the room without identifying herself and later learned from staff that the individual was the involved CNA.R1 stated, I feel safe as long as she's not around me. R1 further stated, I just want them to keep her as far away from me as they can get, because I don't trust her. R1 indicated, Even if she was assigned to be there, she should have said, I cannot go into that room, assign me somewhere else. R1 indicated the facility had informed R1 that the involved CNA would not provide care to or be near R1. R1 expressed concern and distrust toward the CNA and reported becoming frightened after learning that the CNA had entered the room despite those assurances.On 06/10/2026 in the morning, the Social Services Assistant (SSA) confirmed the involved CNA had been assigned to R1's room on 06/01/2026. The SSA indicated it was not appropriate for the involved CNA to be assigned to the same room and that the involved CNA should not have been in R1's room following the abuse allegation reported on 05/02/2026. The SSA indicated that during the interview, R1 appeared more agitated and stressed after learning the involved CNA had entered the room and repeatedly verbalized that the CNA was not wanted in the room.On 06/10/2026 at 12:28 PM, during a telephone interview, the involved CNA denied jabbing, pinching, hitting, or intentionally causing harm to R1 during incontinent care. The involved CNA acknowledged being suspended during the facility's investigation and being reinstated with instructions not to provide care to R1 and not to enter R1's room. The involved CNA stated the assignment to the roommate in the same room occurred on 06/01/2026, to provide care to R1's roommate. The involved CNA acknowledged awareness of the instruction not to have contact with R1 or enter R1's room but entered the room to care for the roommate and did not respond when R1 asked who was in the room, because the CNA believed communication with R1 was prohibited. The involved CNA indicated no attempt was made to notify the Scheduler or facility leadership regarding the assignment or to request a reassignment despite the prior instructions. The involved CNA stated the assignment was accepted because it appeared on the schedule and the CNA believed it was permissible to care for the roommate. The involved CNA acknowledged being instructed after the incident not to enter R1's room at all. The involved CNA indicated education regarding abuse prevention had been received.On 06/10/2026 at 1:30 PM, the Scheduler indicated awareness that the involved CNA was not to be assigned to R1; however, the Scheduler believed the restriction was based on resident preference and was unaware the involved CNA had been associated with a physical abuse allegation. The Scheduler stated, I was advised she couldn't work with the patient, so that's why I scheduled her to still work with Bed A. The Scheduler acknowledged becoming aware of the concern only after R1 complained that the involved CNA should not have been assigned to R1's room. The Scheduler acknowledged that assigning the involved CNA to the same room could have caused fear and emotional distress to R1 and stated, I would be scared too. Following R1's complaint, the involved CNA was removed from all assignments involving the room only after that incident.On 06/06/2026 at 2:15 PM, the Director of Nursing and the Social Worker indicated the involved CNA was suspended pending investigation of abuse allegation and reinstated. The Social Worker indicated the involved CNA was instructed not to be assigned to or provide care for R1 and should not be in the room at all. The Director of Nursing indicated that if the involved CNA entered R1's room, such action was inconsistent with prior instructions. The Social Worker indicated the involved CNA was expected to follow the instruction not to enter R1's room following the abuse allegation.A facility policy titled Patient Abuse Prevention (undated) revealed that the facility was responsible for ensuring residents were free from all forms of abuse, including physical abuse, and for protecting residents from abuse, neglect, exploitation, and mistreatment.FRI #3002223

Based on observation, interview, record review, and document review, the facility failed to ensure a resident was free from physical abuse for 1 of 3 sampled residents (Resident 3). The deficient practice placed residents at risk for emotional distress.Findings include:1) Resident 3 (R3) was admitted on [DATE], with diagnoses including complete lesion at thoracic vertebra (T11-T12) and chronic kidney disease stage four.On 04/06/2026 at 9:30 AM, R3 had a bandage on the left hand dated 04/05. R3 recounted having an altercation with a former roommate whom R3 described as a crazy person who yelled at staff all day. R3 indicated upon being told to stop yelling, R4 hit R3 with a telephone on the left hand. R3 touched bandage on left hand indicating this was the injury which resulted from the incident.A Resident Event form dated 03/27/2026, documented R3 was involved in a resident-to-resident altercation with roommate.An Incident Narrative dated 03/27/2026, documented R4 hit R3 with a phone on the hand R3 refused X-ray but a skin tear was noted. Treatment orders obtained.A Skin/Wound Progress Note dated 03/27/2026, documented skin assessment done. Noted with left dorsal hand skin tear measuring Length 1.5 centimeters (cm) x Width 0.5 cm x Depth superficial, red, with blood tinge on the site. Also noted with small dark red discolorations on the left dorsal hand. No swelling on left hand. Notified wound doctor with new order, noted and carried out. First aid done.2) Resident 4 (R4) was admitted on [DATE] and readmitted on [DATE], with diagnoses including idiopathic neuropathy, hemiplegia and hemiparesis due to cerebrovascular accident.The admission Minimum Data Set (MDS) dated [DATE], revealed R4 had intact cognition and no behaviors.A Physician Order dated 03/30/2026, documented to transfer R4 to hospital on Legal 2000 (mental health crisis hold) for physical aggression toward another resident.A Nursing Note dated 03/27/2026 revealed R4 hit R3 with telephone on left hand and R4 was transferred to the hospital for psychiatric evaluation. Law enforcement involved.On 04/06/2026 at 11:38 AM, social services indicated the facility substantiated the abuse because R4 admitted hitting R3 with phone on the hand and did so willfully.On 04/06/2026 at 11:39 AM, the Director of Nursing (DON) indicated the incident was not witnessed but a therapy staff member was close by and entered the room upon hearing a commotion. The therapy staff member indicated R4 admitted to hitting R3 with a telephone.On 04/06/2026 at 12:23 PM, the Social Services Director (SSD), DON, Director of Staff Development (DSD) and Assistant Administrator indicated the facility investigation concluded physical abuse was substantiated because R4 hit R3 with willful intent and an injury was sustained by R3.On 04/06/2026 at 12:10 PM, the DSD enumerated the following corrective actions taken by the facility after the incident:- R4 (aggressor) was separated from R3 and was transferred to hospital for psychiatric evaluation and admitted to the sister facility on 04/01/2026.- R3 was provided with a psychiatric evaluation.- Wound consult and treatments were provided for R3's hand injury- In-service on physical abuse was provided to staff on 03/27/2026On 04/06/2026 at 9:30 AM, R3 revealed feeling safe at facility, stated injury did not hurt and the incident did not cause emotional distress or mental anguish. R3 reported the facility took care of the wound and R3 expressed no issues with care.The Patient Abuse and Prevention policy dated October 2010 defined abuse as willful infliction of injury. Physical abuse included assault with a weapon likely to produce bodily harm.FRI 2969209

Based on observation, interview, record review and document review, the facility failed to ensure allegations of physical abuse were submitted to the state agency within 24 hours of the facility being informed of the allegation for 2 of 2 reports reviewed. The deficient practice placed residents at risk for abuse.Findings include: 1) Resident 1 (R1) was admitted on [DATE], with diagnoses including multiple fractures from motor vehicular accident and depression.A Facility Incident Report revealed R1 alleged a certified nursing assistant (CNA) on hit R1 on the face on 02/14/2026 at approximately 8:10 PM, after R1 used foul language toward the CNA. Law enforcement came to the facility to interview R1, R1's roommate and the CNA of concern.On 04/06/2026 at 9:08 AM, the Charge Nurse on duty on the evening of the incident indicated completing a Report Event form for the Director of Nursing (DON) and an Incident Narrative form dated 02/14/2026, which was a written form of communicating the alleged physical abuse incident to the DON involving R1.On 04/06/2026 in the morning, the DON explained this incident occurred on a Friday evening and the DON learned of the incident on 02/16/2026 (Monday) after reading the forms completed by the charge nurse. The DON indicated initiating an investigation along with the Social Services Director (SSD) and submitted the report to the state agency as an initial and final on 02/17/2026. The DON acknowledged the facility reports were not submitted to the state agency within the 24-hour mandated window.The state agency received the initial report of the alleged physical abuse on 02/17/2026 at 12:12 PM.2) A Facility Incident Report revealed R4 hit R3 with a phone which resulted in a skin tear to R3's left hand on 03/27/2026 at approximately 5:00 PM. Law enforcement came to the facility and R4 was ordered to be sent to hospital for psychiatric evaluation.The facility submitted the initial report to the state agency on 04/02/2026 at 2:43 PM.On 04/06/2026 in the morning, the DON explained the incident between R3 and R4 occurred on a Friday evening, and the DON learned of the incident on 03/30/2026 (Monday). An initial and final report was submitted to the state agency on 04/02/2026. The DON acknowledged the allegation of physical abuse involving R3 and R4 was not submitted within the 24-hour mandated window.On 04/06/2026 at 12:17 PM, the Assistant Administrator explained being under the impression allegations of abuse were to be reported within 24 hours business days and not calendar days. The Assistant Administrator confirmed the incidents of alleged physical abuse involving Residents 1, 3 and 4 were submitted to the state agency late.The Abuse Investigation and Reporting policy revised July 2017 revealed an alleged violation of abuse would be reported immediately, but not later than 1) two hours if alleged violation involved abuse or resulted in serious bodily harm and 2) 24 hours if the alleged violation did not involve abuse and did not result in serious bodily harm.FRI 2746045FRI 2969209

Based on interview, record review and document review, the facility failed to provide documented evidence foot wound treatments were provided per the physician's order for 1 of 23 sampled residents (Resident 84). The deficient practice had the potential to place the resident at risk for delayed healing of a wound.Findings include:Resident 84 (R84) was admitted on [DATE] with diagnoses including idiopathic peripheral autonomic neuropathy, chronic obstructive pulmonary disease, and arthropathic psoriasis.On 07/16/2025 at 8:52 AM, R84 explained that they had wounds on both feet and back and the staff performing wound care went on leave and no one provided wound treatment. A Physician Order dated 06/19/2025 documented cleanse right foot with normal saline, pat dry, apply Clobetasol 0.05% cream and leave open to air every day for 30 days for diagnosis of psoriasis A Physician Order dated 06/19/2025 documented cleanse left foot with normal saline, pat dry, apply Clobetasol 0.05% cream and leave open to air every day for 30 days for diagnosis of psoriasis. R84's July 2025 Treatment Administration Record (TAR) lacked documented evidence treatments for the right foot and left foot were completed on 07/01/2025, 07/13/2025, and 07/14/2025.On 07/17/2025 at 2:23 PM, a Wound Care Nurse explained having performed wound treatments for R84 and the wound care was scheduled for daily treatments as ordered. The Wound Care Nurse reviewed R84's TAR and confirmed there were no signatures for 07/01/2025, 07/13/2025, and 07/14/2025. The Wound Care Nurse explained an absence of a signature would indicate the treatment was not performed and was not able to answer for what transpired when not in the facility. On 07/18/2025 at 12:13 PM, the Director of Nursing (DON) explained when a resident had treatment orders the nurse would sign the TAR to indicate the treatment was provided. The treatment nurse was responsible for completing wound treatments. The DON reviewed the July 2025 TAR for R84 and verified the record had no signatures for 07/01/2025, 07/13/2025, and 07/14/2025. The DON explained no signature would indicate the treatment was not performed. The DON explained when treatments were not done it could delay wound improvement or healing. The facility policy titled Wound Care, revised October 2017, documented the facility was to provide wound care to promote healing and provide wound care treatments as ordered.

Based on observation, interview and document review, the facility failed to ensure medication was properly labeled and stored. The deficient practice had the potential for non-viable medication to be administered to a resident. Findings include:On 07/17/2025 at 3:44 PM, inside the 300 Hall medication cart was a multi-dose vial of Applisol purified protein derivative (PPD) Tuberculosis (TB) 1 milliliter vial. The box of the vial had a labeled date of 7/10. The nurse in charge of the medication cart was not able to determine if the labeled date was the open date or the discard date. The nurse confirmed the labeling of the medication was not clear and should have been labeled with an open and discard date. The nurse indicated the medication should have been kept in the medication refrigerator and medication kept outside its recommended storage temperature would have rendered it not safe to be administered. The facility policy titled Storage of Medications revised November 2020, documented drugs and biologicals used in the facility are stored in locked compartments under proper temperatures, light and humidity controls.

Based on observation, interview and document review, the facility failed to ensure preventative maintenance (PM) was performed annually for medical equipment being used for 2 of 23 sampled residents (Resident 30 and 40). The deficient practice had the potential for a resident not to receive the intended function of a medical device.Findings include:1) Resident 30 (R30) was admitted on [DATE], with diagnoses including cerebral infarction and physical debility.R30's physician's order dated 11/12/2024, documented to administer Oxygen at 2 liters via nasal canula continuously.On 07/16/2025 at 10:08 AM, R30's Oxygen concentrator (a medical device that extracts oxygen from ambient air and delivers it to a patient) had a PM sticker documented PM date: 05/23/2023, Due 05/24/2024. R30 received supplemental Oxygen from the same medical equipment.On 07/16/2025 at 10:15 AM, the maintenance personnel checked the medical equipment and confirmed the PM was outdated and should have been serviced more than a year ago.2) Resident 40 (R40) was admitted on [DATE], with diagnoses including atherosclerotic heart disease and myocardial infarction.R40's physician's order dated 04/16/2025, documented to administer Oxygen at 3 liters via nasal canula continuously.On 07/17/2025 at 3:18 PM, R40's Oxygen concentrator had a PM sticker documented PM date: 05/2024, Due 05/2025. R40 was currently receiving supplemental Oxygen from the same medical equipment. The nurse caring for R40 was at bedside and confirmed the finding and indicated the medical device should have been serviced months ago.On 07/18/2025 at 8:21 AM, a maintenance staff member indicated the head of maintenance was out on leave and was responsible for ensuring BioMed (a professional who installs, maintains, and repairs medical equipment in healthcare facilities) completed yearly maintenance of the medical equipment throughout the facility. The maintenance staff member acknowledged the O2 concentrators were out of the yearly PM. The maintenance personnel indicated BioMedical service ensures calibration was correct and the medical equipment performed efficiently for its intended use.The facility policy titled Maintenance Service revised 12/2009, documented the Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on observation, interview, record review, and document review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 24 sampled residents (Resident 52). The deficient practice had the potential for residents to not receive necessary behavioral health services. Findings include: Resident 52 (R52) R52 was admitted on [DATE], with primary diagnoses including hypertension, neuropathy, atrial fibrillation, and right hip fracture. A PASARR level one document dated 03/22/2022, revealed R52 did not have dementia, mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility placement. The resident face sheet noted on 10/01/2022, R52 had been diagnosed with dementia. A Psychiatry Note dated 05/29/2024 revealed R52 had disorganized thought process and limited concentration and insight. The resident had a neurocognitive disorder with intermittent agitation and behavioral disturbances that improved with the patient's compliance with medications. The resident was taking Risperidone 0.5 milligrams (mg) for psychosis and Vistaril 50 mg for anxiety. The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities, or related condition, a PASARR Level II screening must be completed to evaluate the individual and determine if nursing facility services and/or specialized services are needed and can be provided in the nursing facility. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASARR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority. The medical record lacked documented evidence R52 was referred for a PASARR level two. On 06/27/2024 in the afternoon, the Social Worker (SW) explained the SW was responsible for completing the online PASARR requests. The SW indicated not being aware of some residents who should have been identified for meeting criteria and referred for PASARR two reviews. The SW agreed a PASARR two referral for R52 had not been done.

Based on interview, record review and document review, the facility failed to provide documented evidence a discharge plan was initiated and discussed with the resident and/or resident representative for 1 of 24 sampled residents (Resident 190). The deficient practice had the potential for the resident to be unprepared for discharge. Findings include: Resident 190 (R190) R190 was admitted on [DATE], with diagnoses including schizoaffective disorder (bipolar type) and suicidal ideations. The Admission Care Plan dated 06/12/2024, documented the interventions to be provided to R190 which included to begin discharge planning. R190's medical record lacked documented evidence a discharge plan was initiated and discussed with the resident and/or resident representative. On 06/28/2024 at 7:29 AM, the Social Services (SS) Director indicated the SS Assistant would have talked to the resident and/or resident representative within 24 hours upon admission and discussed briefly about discharge planning. The SS Director would have followed-up within a week and thoroughly discussed the discharge planning with the resident and/or resident representative. The SS Director explained the discussion and interview about discharge planning would have been documented in the SS Notes. The SS Director revealed the Interdisciplinary Team (IDT) would have discussed the discharge plan with the resident and/or resident representative within 14 days from admission. The SS Director acknowledged there was no documentation of the resident's discharge planning, discussion with the resident and/or resident representative about the discharge plan, IDT notes regarding R190's discharge plan, and no Social Services Progress Notes completed and filed in R190's medical record. On 06/28/2024 at 8:52 AM, the Medical Records Supervisor indicated R190's medical record did not contain IDT Notes. On 06/28/2024 at 11:18 AM, the SS Assistant revealed being in-charge with scheduling the IDT meeting for each resident every 14 days upon admission, quarterly, and as needed. The SS Assistant confirmed there was no IDT meeting scheduled for R190 this week (from 06/23/2024 to 06/29/2024) and next week (from 06/30/2024 to 07/06/2024). The SS Assistant provided a copy of the IDT Weekly Planner which corroborated the interview. The facility's policy titled Discharge Planning dated October 2012, documented discharge planning should be developed at the time of admission and reviewed at least once in every quarter. Discharge plans should be documented in the resident's clinical (medical) record. Upon admission, Social Services should determine the potential for the resident to be discharged to a lower level of care or home care. Reasons for lack of potential should be documented in the social services progress notes and discharge plans. Resident and/or family or responsible party should be involved in the formulation of discharge plans and post discharge care.

Based on interview, record review and document review, the facility failed to ensure as needed (PRN) psychotropic medications were initially ordered for a duration not to exceed 14 days for 3 of 24 sampled residents (Resident 11, 64, and 188); and consents for the administration of psychotropic medications were obtained for 2 of 24 sampled residents (Resident 64 and 188). The deficient practices had the potential to cause an adverse medication effect and not honoring the resident's rights to be fully informed of the care and services being provided. Findings include: 1) Resident 11 (R11) R11 was admitted on [DATE] with diagnoses including generalized anxiety. On 06/27/24 at 9:20 AM, R11 reported taking a medication to treat symptoms of intermittent anxiety. The resident reported they asked a nurse for the medication when the symptoms occurred. A physician order dated 05/24/2024 indicated to give Alprazolam (an antianxiety agent) 0.5 milligrams (mg) by mouth every six hours as needed for anxiety manifested by inability to relax for 30 days. On 06/27/2024 at 2:36 PM, the Director of Nursing (DON) reviewed R11's order for Alprazolam and verbalized the medication was a sedative and should not have been initially ordered for a duration of more than 14 days. On 06/27/2024, at 3:35 PM, the Consultant Pharmacist verbalized initial orders for psychotropic medications should not exceed 14 days duration. 33980 2) Resident 188 (R188) R188 was admitted on [DATE], with diagnoses including major depressive disorder, bipolar disorder, and post-traumatic stress disorder. The physician order dated 06/14/2024, documented Lorazepam (an antianxiety agent) 0.5 milligram (mg) one tablet by mouth every 24 hours as needed (PRN) for anxiety manifested by inability to relax for 30 Days. R188's Medication Administration Record (MAR) for June 2024, documented the resident received the medication on 06/17/2024. R188's medical record lacked documented evidence of the rationale for the duration of the PRN order beyond 14 days and a consent was obtained for the administration of Lorazepam 0.5 mg. On 06/27/2024 at 11:38 AM, the Director of Nursing (DON) confirmed the findings. The DON explained PRN orders for psychotropic medications should have been limited for 14 days, then could have been extended by the physician with the justification for ordering the medications beyond 14 days. The justification should have been documented in the resident's medical record. The DON confirmed the PRN order for R188's Lorazepam dated 06/14/2024 was for 30 days. The DON acknowledged the duration of the PRN order should have been 14 days. The DON explained a consent for the administration of psychotropic medication should have been obtained whether the medication was scheduled or PRN. The DON confirmed there was no consent obtained for R188's Lorazepam. On 06/27/2024 at 12:24 PM, the Medical Records Supervisor confirmed there was no consent for R188's Lorazepam. On 06/27/2024 at 12:49 PM, a Licensed Practical Nurse (LPN) explained the duration of the order for PRN psychotropic medications should have not exceeded 14 days. The LPN revealed the nurse should have called the physician if they received a PRN psychotropic order for more than 14 days. The nurse would have informed the physician the PRN order should have been for 14 days only. The LPN indicated the nurse who received the physician order for the administration of psychotropic medications should have obtained a consent from the resident or resident representative. 3) Resident 64 (R64) R64 was admitted on [DATE], with diagnoses including dementia and shortness of breath. The physician order dated 06/14/2024, documented Hydroxyzine Hydrochloride (HCl) (an antianxiety agent) 25 mg one tablet by mouth three times a day as needed for anxiety manifested by inability to relax for 30 days. R64's medical record lacked documented evidence of the rationale for the duration of the PRN order beyond 14 days and a consent was obtained for the administration of Hydroxyzine HCl 25 mg. On 06/27/2024 at 1:44 PM, the Medical Records Supervisor and the DON confirmed there was no consent obtained for R64's Hydroxyzine HCl. The Acknowledgment of Psychoactive Medication Use form (consent) for the resident's Hydroxyzine HCl was not completed. The DON acknowledged the duration of the PRN order for R64's Hydroxyzine HCl 25 mg was 30 days and there was no justification for the PRN order beyond 14 days. The DON indicated the duration of the PRN order should have been 14 days. The facility's policy titled Psychotropic Drug Treatment dated December 2016, documented psychotropic drugs included antianxiety agents, antidepressants, hypnotics, antipsychotics, and other drugs which would affect behavior. The need to continue PRN orders for psychotropic medications beyond 14 days required the practitioner documented the rationale for the extended order. The resident or his/her representative would be given information regarding the need for, the desired effects and the potential side effects of the medication. This would enable the resident or his/her representative to make an informed decision regarding the use of any psychoactive medication. The resident or their representative should be involved in the medication management process and aware of the benefits and risks of medications and the goals of treatment.

Based on observation, interview, record review and document review, the facility failed to ensure dietary orders were followed for a resident on a renal diet for 1 of 24 sampled residents (Resident 47). This deficient practice placed the resident at risk for weight loss. Findings include: Resident 47 (R47) R47 was readmitted on [DATE] with diagnoses including end stage renal disease, anemia, debility, benign prostatic hyperplasia, and hypertension. The Admission Care Plan dated 06/07/2024, indicated the resident required skilled nursing due to the need to medically manage assistance with meals, offering and encouraging fluid intake, monitoring of weekly weights, and providing and serving diet as ordered to avoid any declines in nutrition. A Physician Order dated 05/31/2024, with a start date of 06/08/2024 documented a renal diet, with regular texture, and thin liquids. A telephone Physician Admission Orders form dated 06/07/2024, indicated a renal diet consisting of regular textures with thin liquids. On 06/27/2024 at 3:07 PM, the Admission Nurse indicated the report was taken from the referring facility. When the referring facility called, they provided all the information to the accepting facility's admission nurse. The admission nurse takes down the information and documents it in the telephone Physician Admission Orders form. The admissions nurse validated the diet written in the orders was renal diet, regular texture, with thin liquids. On 06/25/2024 in the afternoon, R47 voiced the food was always the same. They never change it up. It was always a meat, mashed potatoes or rice, and a vegetable. R47 did not really like the food was all chopped up. R47 complained they never serve salads due to the ordered diet. R47 really wanted a salad. The meal ticket documented a renal diet with mechanical soft texture and thin liquids. On 06/28/2024 at approximately 9:46 AM, the Dietary Manager explained upon admission the kitchen received a written notification from nursing as to the diet, consistency, and allergies. Within a couple days, if there was an upgrade or a down grade, the kitchen would get a written notification. Within the first 48 hours of admission, the kitchen would complete a food preference and snack availability form. The Dietary Manager stated R47 came to the kitchen all the time requesting a salad. The Dietary Manager discussed having to explain to R47 that a salad was not within the mechanical soft texture requirements. On 06/27/2024 at approximately 1:10 PM, a Speech Therapist explained the process of receiving diet orders when a resident was admitted to the facility. The resident was given the diet of the last place they were at unless the physician ordered a Speech Therapy evaluation for food diet and/or textures. The Speech Therapist acknowledged there was not an order written for this evaluation after R47 was readmitted . A facility document titled Diet Order Form and Communication dated 06/08/2024 was completed by a Licensed Practical Nurse (LPN) who was not available for an interview. The regular diet was crossed out and the renal diet was checked. The mechanical soft texture was checked. The regular fluid consistency was checked. On 06/27/2024 at 12:17 PM, a Registered Dietician explained R47 was on a mechanical soft diet for a very long time before the resident left here. At the rehabilitation facility, the resident's diet was upgraded to a regular texture diet. The dietician stated it was possible this facility just kept R47 on the last known diet from this facility being that R47 had been on this texture diet for so long before leaving to go to Rehab. A facility document titled Weekly Weight Record, dated 06/07/2024, indicated the patient had lost 1.5 pounds from 06/17/2024 to 06/24/2024. A facility policy titled Food and Nutritional Services, revised October 2017, indicated each resident will be given a resident-centered diet and nutritional plan that is based on a multidisciplinary assessment to provide a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on interview, record review and document review, the facility failed to ensure the medical record contained the nurse's notes and weekly summary form for 1 of 24 sampled residents (Resident 188). The deficient practice had the potential for the resident not to receive the timely interventions needed and for the facility missing the opportunity to identify care issues. Findings include: Resident 188 (R188) R188 was admitted on [DATE], with diagnoses including major depressive disorder, bipolar disorder, and post-traumatic stress disorder. A review of R188's medical record revealed there were no nurse's notes and weekly summary form completed and filed in the resident's medical record. On 06/27/2024 at 11:38 AM, the Director of Nursing (DON) confirmed the findings and revealed the nurses were expected to complete the 72-Hour Nurses Charting form every shift upon a resident's admission and a weekly summary form for each resident. On 06/27/2024 at 12:24 PM, the Medical Records Supervisor confirmed there were no nurse's notes, 72-Hour Nurses Charting form, Daily Skilled Nursing Notes, and Weekly Summary charting in the medical record of R188. On 06/27/2024 at 12:56 PM, a Licensed Practical Nurse (LPN) indicated the following forms should have been completed and filed in the resident's medical record: - 72-Hour Nurses Charting form for all residents upon admission - Daily Skilled Nursing Notes for Medicare residents and residents receiving therapy - Weekly Summary charting for all residents The facility's policy titled Order of Record Assembling dated December 2006, documented the contents of a resident's medical record which included nurse's notes and assessment.

Based on interview, record review and document review, the facility failed to develop and implement at least one Performance Improvement Project (PIP) per year. The deficient practices had the potential to adversely impact each resident's well-being. Findings include: On 06/28/2024 at 1:17 PM, the Administrator revealed Quality Assurance Performance Improvement (QAPI) committee meetings were held monthly and usual attendees included the Administrator, the Medical Director, and the Director of Nursing. On 06/28/24 at 1:25 PM, the Director of Nursing (DON) reported the facility had a PIP planned for improving laboratory result timelines. There had been a problem with laboratory studies not being completed because of sample degradation through hemolysis. The DON described an intention to improve the laboratory service but was unable to provide documentation of the method of data collection, the analysis of the data, development of an action plan, implementation of the action plan, evaluation of the action plan, and any modifications to the plan if needed, and the target goal. The DON verbalized development of the PIP had not been done yet. The DON verbalized lacking documentation of a PIP which had been completed over the past year. On 06/28/24, in the afternoon, the Administrator indicated the facility was unable to furnish documentation of a PIP completed within the past year. The Quality Assurance/Process Improvement (QAPI) Plan dated 01/12/2023 indicated QAPI committee meetings would be held monthly. Performance Improvement Projects (PIPs) were established by the committee based on potential for negative outcome, number of residents affected, and if the issue was recurring. Data would be reviewed, and improvement or deterioration would be readdressed. Depending on findings the PIP would continue until improvement was maintained. Data would be maintained in the QAPI binder.

Based on interview, record review, and document review, the facility failed to: 1) ensure incidents of resident-to-resident altercations were investigated and interventions implemented to prevent future occurrences for 4 of 11 sampled residents (Resident #4, #5, #1 and #6), and 2) investigate and determine the cause of a resident's bruises and rule out abuse for 1 of 11 sampled residents (Resident #7), and 3) protect other residents from a resident's inappropriate sexual behaviors for 1 of 11 sampled residents (Resident #2) in the facility's pediatric unit. Findings include: Resident #4 (R4) R4 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. R4 was [AGE] years old. A Nurse's Note dated 06/11/19, documented R4 had an [MEDICAL CONDITION] manifested by attempting to punch another resident, thrashing out and yelling. A Nurse's Note dated 06/16/19, documented R4 had an aggressive behavior manifested by attempting to punch another resident. On 10/30/19 at 1:16 PM, the Charge Nurse and the Director of Nursing (DON) indicated not being aware of the incident on 06/16/19 and not knowing the other residents R4 had attempted to punch on 06/11/19 and 06/16/19. The medical record lacked documented evidence interventions were in place and implemented to prevent a reoccurrence of R4's aggressive behaviors on 06/11/19 and 06/16/19. Care plans were not updated to address R4's aggressive behaviors on 06/11/19 and 06/16/19. The history and physical examination [REDACTED]. R4 had a couple of severe episodes at the facility when R4 got mad and threatened some of the staff. R4 was unable to be redirected and was transferred to the Treatment Center. A Nurse's Note dated 07/08/19, documented R4 was observed going to other residents' rooms and began to pick a fight with another resident. R4 had wanted to hit the other resident, but the sitter stopped R4. R4 grabbed a bottled drink and threw it by the door with other children around. R4 began acting up again and kicked the nurse's station door, making a hole in it. The medical record lacked documented evidence interventions were in place and implemented to prevent a reoccurrence of R4's aggressive behavior on 07/08/19 and to protect other residents from these behaviors. Care plans were not updated to address R4's aggressive behavior on 07/08/19. On 10/30/19 at 1:17 PM, the Charge Nurse and the Director of Nursing (DON) indicated not being aware of the incident on 07/08/19 and not knowing the other resident involved in the altercation. A Nurse's Note dated 07/11/19, documented the school called and stated R4 stabbed self with a pen at school and R4 claimed of cutting self with a knife at the facility. The medical record lacked documented evidence the care plan was updated to address R4's behaviors. The history and physical examination [REDACTED]. The resident has been hospitalized at a treatment center twice within the last two months for conduct disorder and aggression. A Nurse's Note dated 08/05/19, documented R4 had an aggressive behavior when one of the younger residents went inside R4's room. R4 tried to wrap an arm around the other resident's neck and was able to release the other resident but started throwing out all of the belongings in the room to the floor. The medical record lacked documented evidence interventions were in place and implemented to prevent a reoccurrence of R4's aggressive behavior and to protect other residents from these behaviors following the altercation on 08/05/19. On 10/30/19 at 1:18 PM, the Charge Nurse and the Director of Nursing (DON) confirmed there was no investigation done for the altercation involving R4 on 08/05/19. The Charge Nurse and the DON were not aware which younger resident had been involved during the altercation on 08/05/19. On 10/30/19 at 1:49 PM, the Social Worker (SW) indicated not being aware of the altercation involving R4 on 08/05/19. On 10/30/19 at 2:00 PM, the Administrator explained had just started working as the Administrator of the facility in (MONTH) 2019 and was not aware of the altercation on 08/05/19. On 10/30/19 in the afternoon, the Assistant Administrator acknowledged not being aware of the altercation on 08/05/19. The Assistant Administrator indicated the altercation should have been investigated further. Resident #5 (R5) R5 was admitted on [DATE], with [DIAGNOSES REDACTED]. The history and physical examination [REDACTED]. A Nurse's Note dated 09/11/19, documented R5 was seen with aggressive behavior by pulling someone's hair. On 10/30/19 at 1:21 PM, the Charge Nurse, the DON, Assistant Administrator and the Administrator confirmed the facility did not investigate the altercation involving R5 on 09/11/19. A Nurse's Note dated 09/13/19, documented R5 was showing more aggression to others. A Nurse's Note dated 09/16/19, documented the Registered Nurse (RN) was made aware by the SW and a Certified Nursing Assistant (CNA) regarding R5's aggressive behaviors toward other children in the hall. R5 was witnessed pinching and scratching other residents. A Nurse's Note dated 10/16/19, documented R5 had an episode of aggressive behavior. R5 slapped another resident on the head and pulled the other resident's hair. The medical record lacked documented evidence interventions were in place and implemented to prevent R5 from hurting other residents and behavioral interventions were in place to handle R5's increased aggressive behaviors. On 10/30/19 at 9:14 AM, an RN indicated the children would play with each other and sometimes would get rough and fight. A staff member would be expected to watch the children at all times. The RN indicated it was normal for kids to play rough. The RN indicated they do not usually report rough playing and fighting because they were just typical children. On 10/30/19 at 11:56 AM, a CNA indicated the residents would have tantrums, would get mad and would throw things. These behaviors would be reported to the nurse or to the SW. On 10/30/19 in the afternoon, the SW explained R5 was identified in the Minimum Data Set (MDS) Assessment with behaviors. The staff were aware of R5's behaviors and it was normal for R5 to exhibit those behaviors. The SW could not provide an answer on how the facility was able to protect the other residents in the Pediatric Unit from R5's known aggressive behaviors. On 10/30/19 at 1:25 PM, the Charge Nurse, the DON, the Assistant Administrator and the Administrator confirmed there was no investigation done to see which residents were pinched and scratched by R5 on 09/16/19. A Nurse's Note dated 09/21/19, documented R5 was very difficult to redirect. R5 had been witnessed by staff members smacking or pinching other residents in the unit. On 10/30/19 at 9:18 AM, an RN indicated not needing to intervene with R5's aggressive behaviors to other residents because they were all just typical children playing with each other. The RN acknowledged not realizing the other residents had to be protected from R5's continued and increased aggressive behaviors. On 10/30/19 at 1:25 PM, the Charge Nurse, the DON, the Assistant Administrator and the Administrator confirmed there was no investigation completed to determine which residents were smacked and pinched by R5 on 09/21/19. On 10/30/19 at 3:36 PM, a CNA indicated the last time the staff had to intervene during a resident-to-resident altercation was yesterday, 10/29/19. R5 and Resident #7 (R7) fought around 4:00 PM - 5:00 PM. R7 had a unicorn headband which R5 took from R7's room. When R7 saw R5 with the headband, R7 went after R5. The CNA witnessed R5 hit R7 in the right upper arm. The CNA indicated having to immediately separate both residents. The CNA explained R5 had a tendency to take things from others and R5 found pleasure in hurting other residents and making them cry. The CNA indicated the altercation was reported to the nurse yesterday. There was no documentation in the medical record of the altercation between R5 and R7 as of 11/01/19. There was no documented evidence an investigation was initiated. Resident #1 (R1) R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. R1 was three years old. A Nurse's Note dated 10/16/19, documented R1 was slapped in the head and hair was pulled by another resident. R1 cried for a few minutes. The Physician and SW were made aware. The medical record lacked documented evidence a plan of care was initiated to protect R1 from further abusive behaviors from other residents. On 10/30/19 at 1:01 PM, the Assistant Administrator, the DON, the Administrator and a Charge Nurse indicated the incident on 10/16/19 was discussed during their stand-up meeting. R5 (a nine year old) was identified as the one who slapped and pulled R1's hair. It was determined by the Interdisciplinary Team no harm occurred because it was only a slight slap. The Assistant Administrator, the DON, the Administrator and the Charge Nurse confirmed there was no further investigation done for the altercation. Resident #6 (R6) R6 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. R6 was [AGE] years old. A Situation, Background, Assessment, Recommendation (SBAR) note dated 10/19/19, documented R6 was twirling with a scarf when R5 grabbed the scarf, which angered R6. R6 got back at R5 by scratching R5's neck and chest. A Certified Nursing Assistant Note dated 10/19/19, documented R6 slapped R5 across the chest and neck and scratched R5. The medical record lacked documented evidence interventions were initiated and implemented to prevent R5 and R6 from further altercations. On 10/30/19 at 11:58 AM, a RN explained R5 enjoyed teasing other residents and would frequently take away the other residents' toys while they were playing. The RN indicated the incident between R6 and R5 on 10/19/19 was a resident-to-resident altercation and should have been reported to the Abuse Coordinator. On 10/30/19 at 1:54 PM, the Charge Nurse, the DON, the Assistant Administrator and the Administrator confirmed the facility did not investigate the altercation between R5 and R6 on 10/19/19. Resident #7 (R7) R7 was admitted on [DATE], with [DIAGNOSES REDACTED]. R7 was six years old. 1) A Nurse's Note dated 09/16/19, documented the SW, CNA and sitters have observed R7 being pushed by other residents. R7 had multiple fading bruises on arm related to being pinched or pushed. The medical record lacked documented evidence the care plan was updated on 09/16/19, to protect R7 from other residents' aggressive behaviors. On 10/30/19 at 1:57 PM, the Charge Nurse, the DON, the Assistant Administrator and the Administrator confirmed the school reported R7's bruises to DFS, and a DFS Case Manager had come to the facility to investigate the resident's bruising. The Administrator indicated the nursing staff witnessed the altercation, but did not report it timely to the Administrator. The Administrator indicated the staff were expected to immediately report resident-to-resident altercations and injuries of unknown origin to the Administrator, who was the Abuse Coordinator of the facility. 2) A Nurse's Note dated 09/25/19, documented the CNA reported R7 had a bruise on the right shin, grayish-purple in color. The nurse checked the bruise, would continue to monitor the bruise and indicated there were no other issues noted. The medical record lacked documented evidence an investigation was done to see how R7 sustained the bruise. On 10/30/19 at 1:24 PM, the Charge Nurse, the DON, the Assistant Administrator and the Administrator confirmed there was no investigation done to see how R7 sustained the bruise. The Assistant Administrator acknowledged not being made aware of R7's bruise identified on 09/25/19. The Administrator indicated the staff were expected to notify the Abuse Coordinator of any injuries of unknown source such as bruises. 3) A Nurse's Note dated 09/30/19, documented R7 was playing in the playroom. R7 returned to room and was noted with a bruise and small abrasion to the right forehead and right cheek. A Resident Care Plan dated 09/17/19, documented R7 required supervision especially during playtime with other children. The medical record lacked documented evidence an investigation was completed to see how R7 sustained the injuries on 09/30/19, or if R7 had been supervised. On 10/30/19 at 1:29 PM, the Charge Nurse, the DON, the Assistant Administrator and the Administrator confirmed there was no investigation done regarding the injuries on 09/30/19. They were not aware if the resident was just playing or had gotten rough with another resident. They acknowledged R7 required supervision during playtime but the staff were not aware how the resident obtained the bruise and abrasion while in the playroom. They indicated the care plan intervention to supervise R7 during playtime was not followed. 4) A Nurse's Note dated 10/01/19, documented R7 was noted with a bump on the right forehead and a scratch mark to the right cheek. The medical record lacked documented evidence an investigation was done to see how R7 sustained the injuries. On 10/30/19 at 1:29 PM, the Charge Nurse, the DON, the Assistant Administrator and the Administrator confirmed there was no investigation done to see how R7 obtained a bump and scratch mark on the right cheek. 5) A Nurse's Note dated 10/01/19, documented the CNA reported R7 had a bruise on the left anterior foot, purplish in color. The medical record lacked documented evidence an investigation was done to see how R7 sustained the bruise on 10/01/19. On 10/30/19 at 1:31 PM, the Charge Nurse, the DON, the Assistant Administrator and the Administrator confirmed there was no investigation done as to how the resident sustained [REDACTED]. The Assistant Administrator and the Administrator indicated not being made aware of R7's bruise on the left anterior foot. 6) A Nurse's Note dated 10/15/19, documented R7 had a bruise on the back. The medical record lacked documented evidence further investigation was done to check how R7 sustained the bruise on 10/15/19. On 10/30/19 at 1:38 PM, the Charge Nurse, the DON, the Assistant Administrator, the Administrator and the Pediatric Nurse confirmed there was no investigation done to find out how the resident obtained the bruise. They could not indicate when the bruise was initially noted. 7) A Nurse's Note dated 10/16/19, documented R7 was showered and was noted with two quarter-size old bruises on low mid-back, fading to a pale yellow or light brown shade. The medical record lacked documented evidence further investigation was done to check how R7 sustained the bruises on 10/16/19. On 10/30/19 at 1:39 PM, the Charge Nurse, the DON, the Assistant Administrator and the Administrator confirmed there was no investigation done as to how the resident sustained [REDACTED]. On 10/30/19 in the afternoon, the Administrator indicated if an investigation was not thoroughly conducted on how R7 obtained the bruises, then abuse could not be ruled out. On 10/30/19 in the afternoon, the Assistant Administrator, the Administrator, the DON, the Charge Nurse and the SW indicated resident-to-resident altercations and injuries of unknown origin would be discussed during their stand-up meetings and they would determine if a report should be sent to DFS. The Case Managers from DFS would be in the facility every week to discuss each resident and would be informed. The facility policy titled Abuse Prevention Program, revised (MONTH) 2010, documented abuse was defined as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish. Injury of unknown source was defined as an injury that meets both of the following conditions: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury was suspicious because of the extent of the injury or location of the injury (the injury was located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time; or the incidence of injuries over time. The facility policy titled Resident Rights, revised (MONTH) (YEAR), documented a resident had a right to be free of mental and physical abuse. Complaint #NV 153 The facility policy titled Abuse Investigations, dated (MONTH) 2013, documented all reports of resident abuse, neglect and injuries of unknown source would be promptly and thoroughly investigated by facility management. Resident #2 (R2) R2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was in the custody of Department of Family Services (DFS). R2 was two years old. A Nurse's Note dated 09/16/19, documented the resident self-stimulating by placing a blanket on the bed laying on his stomach on top of it, and continuously stimulating a sexual act with the blanket until R2 fell asleep. The nurse's note lacked documented evidence the Social Worker (SW) or the Case Worker with DFS was notified of the resident's behavior. A Nurse's Note dated 09/06/19 documented: while in the dayroom after breakfast, R2 was seen simulating a sexual act with a male peer on the floor. The nurse's note indicated the residents were separated. The note lacked documented evidence the SW, the Director of Nursing (DON), the Administrator or the resident's Case Worker with DFS were notified regarding the resident's sexually inappropriate behavior towards the peer. The nurse's note lacked documented evidence of the identity of the peer. On 10/31/19 at 2:57 PM, a Case Worker with DFS explained the resident had aggressive behaviors which were reported by the facility when the resident was first admitted to the facility. The Case Worker was not made aware of any sexually inappropriate behaviors towards peers or sexual gratification to self. On 10/31/2019 at 3:27 PM, an interview was conducted with facility leadership which included the Assistant Administrator, the DON, the SW, and the Pediatric Nurse Manager. The facility leadership were made aware nursing documentation in the resident's medical record revealed two instances of inappropriate sexual behaviors exhibited by R2. When asked if they were aware of the resident's inappropriate sexual behaviors, the leadership present replied, No, they were not made aware by the nurse the resident simulating a sexual act with a male peer on the floor of the dayroom, nor were they aware of the observation of the resident's sexual self-stimulating behavior to go to sleep. On 10/31/19 in the afternoon, the Assistant Administrator explained if it was reported to them they would have notified the physician of the behaviors. The Assistant Administrator confirmed R2's inappropriate sexual behaviors were not reported. The DON indicated the nurses were expected to report the observations of sexual inappropriate behaviors. On 11/08/19 at 11:00 AM, the RN indicated she observed the incident when R2 was simulating a sexual act on the floor. The RN indicated the resident was redirected and had clothes on. The RN indicated there was no other resident involved. The RN indicated the behavior was documented and reported to the SW. The RN later admitted the incident involved another resident. The RN indicated nothing sexual happened and that this was not a sexual act. The child did not react due to having dow[DIAGNOSES REDACTED]. The RN responded, they had their clothes on. The RN indicated the SW was made aware of the incident. The lack of reporting Resident #2 simulating a sexual act increased the likelihood of reoccurrence placing other residents at risk of experiencing this inappropriate behaviors.

Based on observation, interviews, record review, and document review, the facility failed to ensure each resident had adequate supervision to prevent elopement for 3 of 7 residents (Residents #1, #2, and #3): failed to develop an elopement prevention care plan for 2 of 7 sampled residents (Resident #1 and #7), and failed to perform an elopement risk evaluation for 1 of 7 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 30-Day Scheduled Assessment Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating some impairment of memory. An elopement risk care plan, dated 6/19/17, documented the resident was at risk for elopement as manifested by having impaired decision-making skills, decreased awareness of safety and expressing desire to leave the facility. The care plan documented the facility would assess the resident for risk of elopement, monitor the resident each shift, provide supervision with Activities of Daily Living (ADL's), and redirect the resident during episodes of wanting to leave the facility. There was no documented evidence a Wander-Elopement Risk Evaluation had been completed for the resident. A nursing progress note, dated 7/5/17, documented the resident was observed at the lobby by a nurse and had attempted to leave the facility. The resident rushed out the facility door. A nurse and another staff member brought the resident back into the facility. The resident was identified as an elopement risk and the nurse informed the staff to watch the resident. Hourly checks were initiated for the resident. A nursing progress note, dated 8/11/17 at 6:00 AM, documented the resident had expressed she wanted to go home. The note documented the resident went to her room. A nursing progress note, dated 8/11/17 at 6:30 AM, documented staff had reported the resident was not in her room. Staff searched all rooms, including bathrooms, and the resident was not located. A nurse notified the physician. A nursing progress note, dated 8/11/17 at 8:30 AM, documented the resident's guardian had been notified the resident had eloped. The facility also notified the police department. On 8/17/17 at 12:05 PM, the Director of Nursing (DON) explained staff prevent elopement by conducting visual checks on the resident every two hours. The DON verbalized Resident #3 was placed on hourly checks. The DON acknowledged the resident had eloped from the facility. The DON reported the resident must have left through the front doors. The DON explained the other emergency exit doors (other than the front door) sound an alarm when a resident exits through the doors, and a staff member must go to the door and turn the alarm off. On 8/17/17 at 2:45 PM, the MDS Coordinator confirmed a Wander-Elopement Risk Evaluation was not completed at the time of the resident's admission. The MDS Coordinator indicated the assessment should have been completed, along with an elopement risk care plan. On 9/1/17 at 10 AM, the Licensed Practical Nurse (LPN), reported Resident #3 verbalized multiple times she wanted to leave the facility, but never said where she was going. The LPN stated the resident had exit seeking behavior. The LPN stated while the resident could hold a conversation, the resident had poor judgement and wanted to go out during hot weather conditions. The LPN stated the resident was supposed to get hourly checks, but was not assigned to have direct supervision at all times. The LPN recalled on 8/10/17 at approximately 3:00 PM, staff observed the resident exit the facility via the front door. The LPN stated multiple staff responded and persuaded the resident to re-enter the facility. The LPN stated during this incident, staff attempted to place a Wander Guard (a device worn by the resident which will trigger an alarm when the resident moves through an exit door) on the residents ankle. The LPN reported the attempt was unsuccessful because the resident refused to wear the Wander Guard. On 9/1/17 at 10:20 AM, another LPN reported the resident was noted to have varying degrees of mental confusion during her stay at the facility. The LPN reported the resident verbalized she wanted to go home. The LPN reported on 8/10/17 in the afternoon the resident exited the facility but was brought back in by staff. The LPN stated on 8/11/17 she arrived to work at 6:15 AM and checked on residents assigned to her care. The LPN reported at that time Resident #3 was not seen in her room. The LPN stated staff conducted a search of the facility but the resident was not located. The LPN revealed a staff member went outside on foot to look for the resident, but did not locate the resident. On 9/1/17 at 10:55 AM, the Unit Clerk stated on 8/11/17 at 6:00 AM, Resident #3 approached her near the laundry room area of the facility and inquired about a missing shirt. The Unit Clerk stated after she had expressed her concern about the shirt, Resident #3 walked down the hall and was last seen in the vicinity of the front door. The Unit Clerk revealed the front door area reception desk was not staffed at that time. The Emergency Department (ED) record, dated 8/11/17, documented Emergency Medical Service (EMS) responders brought Resident #3 to the ED via ambulance on 8/11/17 at 1:01 PM. The EMS responders reported Resident #3 was found unresponsive, slumped over next to a car, laying in large amounts of dried vomit. EMS responders reported Resident #3's body temperature was 107.4 degrees Fahrenheit (F) tympanic (a body temperature measured using the eardrum), and the resident's skin felt hot to the touch. The record documented the chief complaint on admission to the ED was heat stroke. Heat stroke is a condition caused by your body overheating, usually as a result of prolonged exposure to or physical exertion in high temperatures. This most serious form of heat injury, heat stroke, can occur if your body temperature rises to 104 F or higher. The condition is most common in the summer months. Heat stroke requires emergency treatment. Untreated heat stroke can quickly damage your brain, heart, kidneys and muscles. The damage worsens the longer treatment is delayed, increasing your risk of serious complications or death. (http://www.mayoclinic.org/diseases-conditions/heat-stroke/home/ovc- 531) The ED record documented Resident #3's temperature was stabilized using a cooling blanket and ice packs. The ED record further documented the resident had a second degree burn (a type of burn characterized by blisters) on the left hip. The History and Physical record, dated 8/11/17, indicated Resident #3 was admitted to the hospital with [REDACTED]. The Wound Assessment Report, dated 8/13/17, documented a partial thickness burn on Resident #3's left hip measuring 16.5 centimeters (cm) long and 14.1 cm wide. The hospital Social Worker notes, dated 8/14/17, indicated Resident #3 was found down next to a vehicle on 8/11/17, at an address on a major urban street. Review of street map data indicated the resident was found by EMS responders approximately 1.3 miles distant from the facility from which she eloped. Review of weather records for the area where the resident was found indicated the air temperature reached 101 degrees F on 8/11/17. Resident #2 Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 30-day Scheduled Assessment Minimum Data Set ((MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated some impairment of memory function. A comprehensive care plan dated 5/16/17, documented the resident had a [DIAGNOSES REDACTED]. Resident was documented as risk for elopement. A Wander-Elopement Risk Evaluation reported on 5/18/17, documented the resident was cognitively impaired, the resident did frequently pace or wander in areas/other resident's rooms without a purpose. The resident did have impaired decision-making skills, but the resident did not want to leave the center. The resident did not express anger at being placed in the facility. The resident was documented as a risk for eloping. The resident's first elopement was on 5/20/17, per the nurse's notes. The resident was found outside the parking lot trying to get into his car to start the engine. Resident was agitated about being asked to go back inside the facility, and expressed to the staff he wanted to leave the facility and go home. On 5/20/17, a comprehensive care plan was created and indicated the facility would monitor the resident every 2 hours, to prevent another elopement. A Nurses note dated 5/21/17, revealed the resident was confused and wanted to leave the facility. A Nurses note dated 6/15/17, documented the resident was ambulatory and required constant supervision. Resident attempted to exit the front doors and was re-directed by staff. PPS Licensed Notes dated 5/25/17, 5/26/17, 5/31/17, 6/19/17, documented the resident was confused and wanted to leave the facility. A Nurses note dated 5/21/17, revealed resident was confused and wanted to leave the facility. A Nurses note on 6/15/17, revealed the resident was ambulatory and required constant supervision. Resident attempted to exit the front doors and was re-directed by staff. Nurses notes dated 6/20/17, document resident was last seen walking in the hallway during shift change at 3:00 PM. On 6/20/17 at 5:00 PM, a Certified Nursing Assistant (CNA), reported the resident's food tray had remained untouched. Staff tried to find the resident in the immediate area and initiated a code Mr. Wander. Staff were unable to locate the resident and noticed the resident's car was gone from the facility's parking lot. The police were notified and reported the resident was missing. The police were sent to the resident's address, but could not locate the resident. The resident's family member was notified the resident was missing. On 6/20/17 at 9:00 PM , the facility still was not able to locate the resident and hospital emergency room s were called. The police tried to locate the resident, but it were unsuccessful. On 8/17/17 at 11:30 AM, the Director of Nursing (DON), confirmed not all elopement risk residents have Wander Guards and did not think the resident had a Wander Guard on. The DON confirmed if a resident tried to leave the facility, they would receive a Wander Guard and it would be documented in the resident's care plan. The DON confirmed the resident surrendered two sets of car keys to the facility, but the resident must have kept a third set of car keys the facility did not know about. The DON stated hourly checks were done on residents who had eloped or were elopement risks. The hourly log check was located at the nurse's station. The DON confirmed a new Wander-Elopement Risk Evaluation should have been completed for the resident after the resident first eloped. On 8/17/17 at 11:30 AM, a Social Worker confirmed the resident's car had arrived at the facility on a later date after the resident had been admitted . On 8/17/17 at 12:00 PM, the Social Worker described the preventative measure the facility took to ensure residents would not elope. This was talking to the residents often (if they are verbal) and visiting the resident every 2 hours to ensure the resident's location. The Minimum Data Set (MDS) coordinator confirmed the resident was supposed to have a log which documented the hourly checks after the residents first elopement, but one was never completed for the resident. On 8/17/17 at 2:45 PM, the Administrator explained there should have been a care plan, including interventions, developed after the resident's first attempt to elope. The Administrator confirmed he assisted the resident in retrieving his car from an impound lot nearby. The car was driven to the facility from the impound lot, by the Administrator and the resident a few days after the resident was admitted . The resident surrendered at that time two sets of car keys to the facility, one to the Administrator and one to the nurse. The Administrator stated the resident liked to go out to the parking lot and visit his car sometimes, and that was not considered wandering or eloping. The Administrator explained he was not made aware the resident attempted to elope on 5/20/17, when the resident was found unescorted in the facility parking lot, trying to start the car. The Administrator revealed after the resident eloped on 6/20/17, police were unable to locate the resident and his whereabouts remained unknown. The Administrator described Resident #2 was difficult to distinguish as a resident versus a visitor. The Administrator stated the resident may have walked outside and not been identified as a resident by staff at the reception desk who kept the front doors under observation. Resident #7 Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 8/17/17 at 9:50 AM, the resident verbalized he had walked out of the facility on two occasions. The resident could not recall when he left the facility, but expressed the date may have been around (MONTH) (YEAR). The resident explained he walked out of the facility and was found intoxicated and brought back to the facility by law enforcement within 24 hours. The resident verbalized there were no staff who witnessed him leave the facility. The clinical record revealed no documented evidence the resident had eloped from the facility. A Wander-Elopement Risk Evaluation, dated 7/5/17, documented the resident was at risk for wandering. There was no documented evidence in the clinical record a care plan for wandering had been developed. On 8/17/17 at 2:15 PM, the Minimum Data Set (MDS) Coordinator confirmed a care plan should have been developed when the resident was assessed on 7/5/17 as at risk for wandering. The MDS Coordinator explained a new Wander-Elopement Risk Evaluation should have been completed for the resident. On 8/17/17 at 2:25 PM, the Director of Nursing (DON) verbalized nursing staff were responsible for completion of the care plan. The DON acknowledged a care plan for wandering or elopement should be developed when a resident was assessed as at risk for wandering or elopement. Resident #1 Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The clinical record contained a quarterly Minimum Data Set (MDS) resident assessment dated [DATE]. The MDS documented the resident had a mental status score of 03 on a scale of 00-15. A score between 00-07 indicated severe impairment. The functional status of the resident was assessed as a 2 for balance during transitions and walking. This indicated the resident was not steady when walking and only able to stabilize with staff assistance. The Wander-Elopement Risk Evaluations dated 3/31/17, and 6/23/17 indicated Resident #1 was not at risk for wandering or elopement. The Wander-Elopement Risk Evaluation dated 7/28/17 indicated Resident #1 was at risk for elopement. A Nursing Note dated 7/28/17 at 8:35 AM, documented the elopement of the resident between 7:00-7:30 AM. The facility was alerted to the resident elopement after an individual from an apartment building stopped by and asked if the resident belonged at the facility. An employee of the facility took a wheelchair to transport the resident from the apartment building back to the facility. The individual from the apartment building indicated the resident was at the apartment for almost one hour. On 8/17/17 at 12:05 PM, the Director of Nursing (DON) declared if a resident attempted to elope, a wanderguard (or other preventative measures) were put in place. On 8/17/17 in the afternoon, the DON confirmed the Elopement Risk Care Plan was not in Resident #1's clinical record. If a Wander Elopement Risk Evaluation was marked yes for elopement, there should be a care plan. The DON stated Nursing was responsible for completing of the Elopement Risk Care plan and placing the plan in the resident's clinical record. On 8/17/17 at 7:15 AM, the facility front doors consisted of two doors situated side by side (a double door). The front doors of the facility were unlocked and there was no receptionist in the front lobby. On 8/17/17 at 7:40 AM, the receptionist was seated at a reception desk in the lobby by the front doors. The receptionist stated she watched the front door area starting at 7:30 AM five days a week. The receptionist reported the front doors were to be locked at all times, unless there was someone at the front reception desk to monitor the doors. The receptionist stated each of the two doors had a lock which prevented both entrance and exit. The receptionist stated she unlocked the doors each morning, and locked them upon leaving in the evening. On 8/17/17 at 7:45 AM, the receptionist locked the front doors using a key inserted into a small hole on each door. The receptionist confirmed the doors were in the locked mode. However, when the doors were pressed upon, the left side door opened. The receptionist stated that had never happened before. The inspector was able to both exit and re-enter the facility through the left front door while it was in the locked position. The receptionist stated the door lock was defective and she would contact maintenance to have it fixed. On 8/17/17 at 8:15 AM, Director of Maintenance confirmed one of two front door locks was not working properly. On 8/17/17 at 2:35 PM, the main (front) entrance was inspected with the Administrator. The Administrator tested the doors, and confirmed one of the two front doors could be opened from inside or outside of the building, when the lock was engaged. The door was supposed to be immobile. The Administrator stated he was not aware the front door lock was not functioning, and was not sure how long the door had been in that condition. On 8/17/17 at 2:45 PM, the Administrator reported the side exit doors from the facility sound an alarm when opened without first entering a numerical code into a keypad. The Administrator revealed the front doors were not equipped with a similar keypad and alarm, but should be so equipped to alert staff when a resident exits from the doors. The Administrator stated the front doors should be locked from 8:00 PM until 7:30 AM to prevent residents from leaving the facility without being observed by staff. The Administrator revealed the front door and lobby area was not observed continuously by staff from about 8:00 PM until 7:30 AM. The Administrator stated Residents #1 and Resident #3 may have eloped from the facility from the unlocked front door during the early morning hours. The facility policy and procedure titled Exit Doors, revised 1/2011, indicated the front doors were unlocked at 7:30 AM and locked at 8:00 PM. The facility policy and procedure titled Maintenance Service, revised 12/2009, indicated the maintenance service would maintain the building in good repair and free from hazards. The facility policy and procedure titledWandering, Unsafe Resident, revised 2/2014, indicated staff would identity residents who were at risk for harm because of unsafe wandering, including elopement. The policy indicated at risk residents would be assessed for potentially correctable risk factors related to unsafe wandering. The policy indicated the resident's care plan would include interventions to maintain safety, such as a detailed monitoring plan. The facility policy and procedure titled Care Planning - Interdisciplinary Team, revised 2/2014, indicated the Interdisciplinary Team including the Registered Nurse and Nursing Assistants were responsible for development of an individualized comprehensive care plan for each resident. The facility policy and procedure titled Safety and Supervision of Residents, revised 12/2008, indicated safety risks and environmental hazards were identified on an ongoing basis through employee monitoring, and reporting processess. Employees would be trained on how to identify and report accident hazards. The facility policy and procedure titled The Use of Wander Guards, revised 12/2008, indicated a Wander Guard (a device placed on the resident which caused an alarm to sound when the resident moves near a sensor, usually placed at exit doors). The policy indicated Wander Guards would be used for each resident identified by assessment as being at risk because of unsafe wandering. The facility policy and procedure titled Elopements, revised 4/2014, indicated staff would promptly report any incident where a resident tried to leave the premises to the Charge Nurse or Director of Nursing. Entity Reported Event #NV 122 Complaints #NV 718, #NV 035, #NV 244

The Nevada Nurse Practice Act: NAC 632.212 Duties included; competency required. 1. The Board will interpret the practice of professional nursing to include, but not be limited to, the duties specified in NAC 632.214, inclusive. 2. A registered nurse shall demonstrate in the performance of those duties competence in: (a) The [DIAGNOSES REDACTED]. (B) Exercising sound judgment; (ac) Making decisions; (d) Carrying out his duties based on an established plan of care; (e) Evaluating, assessing and altering, if appropriate, the established plan of care; (f) Delegating appropriate duties to other nurses; (g) Supervising a nurse to whom he has delegated nursing duties; (h) Maintaining accountability in the delegation of care; (i) Administering medication and carrying out treatments which are properly authorized; (j) Determining the necessity and appropriateness of health care services for a patient or prospective patient and determining that patient's eligibility for payment of those health care services by a licensed insurer; (k) Managing the cases of patients assigned to him by coordinating services and collaborating with other health care professionals in the provision of health care services; (l) Planning for the discharge of patients; and (m) Managing risk in the provision of health care services. (Added to NAC by Bd. of Nursing, eff. 11-2-87; A 6-26-96). Based on interview, clinical record review and document review, the facility failed to ensure a physician's orders [REDACTED].#14); failed to ensure physician's orders [REDACTED].#14): failed to ensure a physician's orders [REDACTED].#14): failed to ensure a physician's orders [REDACTED].#14): Failed to obtain a physician's orders [REDACTED]. Findings include: Resident #14 was re-admitted to the facility on [DATE], and discharged on [DATE], with [DIAGNOSES REDACTED]. The resident was on [MEDICATION NAME] therapy. 1. On 2/12/13 at 10:00 AM, a physician's orders [REDACTED]. (Vitamin K was ordered for high INR to assist with blood clotting). Transfer to the Long Term Acute Care (LTAC, a sub-acute care hospital) facility for transfusion of 4 units Fresh Frozen Plasma.On 2/13/13 at 10:45 AM, a physician's orders [REDACTED]. Vitamin K 10 mg orally times one now for INR (International normalized ratio, a test for blood clotting) of 8.0. (Normal range for an INR 0.8 to 1.2. Note: If the INR gets too high it is taking too long for your blood to clot). A Nurses notes dated 2/12/13 at 1:00 PM, documented the [MEDICATION NAME] time (PT) and INR test results were relayed to the physician. An order was received for Vitamin K 10 milligram (mg) orally times one now and for the resident to be transferred to the LTAC for transfusion of four units of FFP (Fresh Frozen Plasma). The Vitamin K had been administered per orders and "awaiting for bed @ LTAC facility." The resident had no signs of active bleeding. The clinical record lacked documented evidence Resident #14 had been re- assessed after the entry into the nurses notes on 2/12/13 at 1:00 PM, until the entry 2/12/13 at 9:30 PM. On 2/12/13 at 9:30 PM, a nurses note documented the resident was in bed, asleep and responsive. The right upper arm Peripherally Inserted Central Catheter (PICC) line was intact and patent with intravenous fluids ongoing as ordered. On 2/13/13, 12:01 AM, the Licensed Nurse (LN) was called by the Certified Nursing Assistant (CNA). Resident #14's oxygen saturation level was 75% (Note: A normal oxygen saturation level is between 95% to 100%) with oxygen at 3 liters per minute via nasal cannula. The resident was medicated with a Small Volume Nebulizer (SVN) treatment of [REDACTED]. Lungs clear to auscultation (listening to lung sounds). "Resident observed Mental status is altered." Vital signs blood pressure 97/54, respiratory rate 20, pulse rate 70, temperature 96.7 degrees Fahrenheit. (Note: Normal body temperature can range from 97.8? F to 99? F for a healthy adult. The normal pulse for healthy adults ranges from 60 to 100 beats per minute, Normal respiration rates for an adult person at rest range from 15 to 20 breaths per minute and guidelines now define normal blood pressure as follows: Less than 120 mm Hg systolic pressure and Less than 80 millimeters of mercury (mm Hg) diastolic pressure.) Oxygen saturation was 82-85% on "Non Rebreathing mask." Call to the physician and order was received to transfer the resident to the hospital for further evaluation. "911 Medical ambulance came and took over." Spoke with resident representative. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The back of the MAR indicated [REDACTED]. On 2/13/13 at 12:15 AM, a physician's orders [REDACTED]." The clinical record lacked documented evidence the physician had been notified the resident was "awaiting" a bed at a LTAC. The clinical record lacked documented evidence as to why the resident had not been transferred to the LTAC in accordance with the physician's orders [REDACTED]. On 8/28/13 at 2:35 PM, a Licensed Nurse was not able to locate documentation on the February 2013 MAR indicated [REDACTED]. The Licensed Nurse verbalized if the as needed medication was administered the nurse would document on the back of the MAR indicated [REDACTED]. On 8/28/13 at 2:40 PM, a Licensed Nurse (LN) verbalized Resident #14 had an INR of 8.0 and the Vitamin K was administered as ordered. The LN verbalized the FFP would be used to decrease the bleeding time. The LN revealed with just the INR results "it doesn't paint a good picture " of want was going on with the resident. The LN indicated it was not clear why the order for FFP and transfer had not been done. The LN verbalized if a bed was not available or the physician's orders [REDACTED]. The emergency room report dated 2/13/13, documented Resident #14 had been seen in the emergency room (ER) at 1:02 AM. The resident had arrived by ambulance. The documentation revealed the altered mental status started today and was still present. "It was gradual in onset and has been constant." The resident had been disoriented and confused and was described as having decreased responsiveness. The resident was usually alert and orientated times three. The ER report documented the vitals signs were blood pressure 60/ palpable, heart rate 58, respiratory rate 24, oxygen saturation; unable to obtain due to the resident's condition. Skin deep sacral pressure ulcer with necrosis (bilateral buttocks). Necrotic toes to left foot and above the knee amputation right leg. The resident was disoriented. The ER report documented Resident #14 was intubated at 2:23 AM on 2/13/13 and placed on a ventilator. The report reveled the resident had a urinary tract infection and deep decubitus sacral ulceration with surrounding [DIAGNOSES REDACTED]. Disposition: admitted to the ICU (Intensive Care Unit) in Condition Critical Clinical Impression:[MEDICAL CONDITIONS], Urinary Tract Infection, [MEDICAL CONDITION], Pressure ulcer stage unspecified and Ischemic limb. The History and Physical (H&P) from the acute care hospital indicated Resident #14 been admitted on [DATE]. The H&P documented the resident was sent to the acute care hospital for altered mental status and appeared to be unresponsive and arrived with Emergency Medical Service (EMS). The resident was found to be significantly tachypneic (rapid respirations) with diminishing oxygen saturations. The resident was intubated and a chest x-ray showed bibasilar atelectasis and lab results indicated acute [MEDICAL CONDITION]. The resident presented with a significantly low blood pressure requiring multiple vasopressor support. The resident had a significant coccygeal stage 3 decubitus and well as a possible gangrenous left lower extremity toes. Documentation received from the facility entitled Documentation of Resident's Health Status, Needs and Service, dated 10/31/09, revealed, the resident's medical record was a continuing account of the resident's health status and needs, the treatments delivered, results of diagnostic tests and the resident's response to treatment. The Interdisciplinary Team involved in the care of the resident was responsible for recording assessments of a resident's condition, changes in the resident's condition, a detailed accounting of interventions and an evaluation of the resident's progress toward established outcomes. Record pertinent resident data that may include but not limited to: a. Change of condition illness and ongoing monitoring b. Selected subjective data that validates or clarifies c. Action taken d. Notification of physician (name and status) e. Notification of family (name and relation to resident) f. Results of labs and follow-up g. Consultations h. Any unusual or abnormal occurrence i. All telephone calls made or received that are related to the resident j. Refusals, noncompliance, behavior occurrences k. Events and accidents document the details of the event, action taken, notifications, monitoring, and follow-ups. 2. The clinical record lacked documented evidence a physician's orders [REDACTED]. On 8/28/13 at 10:35 AM, a Licensed Nurse (LN) verbalized a physician's orders [REDACTED]. On 8/28/13 at 1:50 PM, a LN confirmed the clinical record lacked documented evidence a physician's orders [REDACTED]. 2. Documentation from the facility entitled Fluid Intake & Output Measurement dated 10/31/06, reveled Intake and Output (I&O) measurement was recorded for residents according to the following criteria: -Residents identified as high risk for dehydration. -Residents with a physician's orders [REDACTED]. -Residents with a physician's orders [REDACTED]. -Residents with indwelling catheters (output only). -residents on intravenous therapy. The document defined fluid intake as all fluid entering the resident's body, including beverages, food that were liquid at room temperature such as flavored gelatin, custard and ice cream. The definition of output revealed all fluid that left the body such as urine, loose stools, emesis. According to the document entitled, Fluid Intake & Output Measurement the documentation guidelines were to record the shift, type and amount of both intake and output. On 2/10/13 a physician's orders [REDACTED]. The clinical record lacked documented evidence Resident #14's oral intake and output had been monitored/ documented on 2/10/13, 2/11/13, 2/12/13 and 2/13/13 in accordance with the physician's orders [REDACTED]. On 8/28/13 at 10:35 AM, a Licensed Nurse (LN) verbalized if a physician ordered I&O the information would be documented on the I&O flow sheet. The documentation would contain a resident's intake of fluids, and documentation of the resident's output of urine and emesis. On 8/28/13 at 1:50 PM, a LN confirmed the clinical record lacked documented evidence I&O's were done in accordance with the physician's orders [REDACTED]. 3. On 2/10/13 a physician's orders [REDACTED]. Resident #14's clinical record contained laboratory test results for the Norovirsus and Ova and Parasites. The clinical record lacked documented evidence of laboratory test results for [MEDICAL CONDITION] in accordance with the physician's orders [REDACTED]. On 8/28/13 at 1:50 PM, a LN confirmed the clinical record lacked documented evidence a laboratory specimen had been tested for [MEDICAL CONDITION] in accordance with the physician's orders [REDACTED]. 4. On 2/10/13 a physician's orders [REDACTED]. The clinical record lacked documented evidence the hospice evaluation had been arranged or completed in accordance with the physician's orders [REDACTED]. On 8/28/13 at 1:50 PM, a LN confirmed the clinical record lacked documented evidence a hospice evaluation had been done in accordance with the physician's orders [REDACTED].

Based on observation, interview, clinical record review and document review, the facility failed to ensure a physician's order to transfer a resident to a Long Term Acute Care facility had been followed for one of 15 sampled residents (Resident #14); failed to ensure physician's order for a hospice evaluation were completed for one of 15 sampled residents (Resident #14): failed to ensure a physician's order was followed for Intake and Output for one of 15 sampled residents (Resident #14); failed to ensure a physician's order was followed for laboratory test for one of 15 sampled residents (Resident #14); Failed to obtain a physician's order for the use of [REDACTED]#9, #3). Findings include: The Nevada Nurse Practice Act: NAC 632.212 Duties included; competency required. 1. The Board will interpret the practice of professional nursing to include, but not be limited to, the duties specified in NAC 632.214, inclusive. 2. A registered nurse shall demonstrate in the performance of those duties competence in: (a) The [DIAGNOSES REDACTED]. (B) Exercising sound judgment; (ac) Making decisions; (d) Carrying out his duties based on an established plan of care; (e) Evaluating, assessing and altering, if appropriate, the established plan of care; (f) Delegating appropriate duties to other nurses; (g) Supervising a nurse to whom he has delegated nursing duties; (h) Maintaining accountability in the delegation of care; (i) Administering medication and carrying out treatments which are properly authorized; (j) Determining the necessity and appropriateness of health care services for a patient or prospective patient and determining that patient's eligibility for payment of those health care services by a licensed insurer; (k) Managing the cases of patients assigned to him by coordinating services and collaborating with other health care professionals in the provision of health care services; (l) Planning for the discharge of patients; and (m) Managing risk in the provision of health care services. (Added to NAC by Bd. of Nursing, eff. 11-2-87; A 6-26-96). Resident #14 was re-admitted to the facility on [DATE], and discharged on [DATE], with [DIAGNOSES REDACTED]. The resident was on [MEDICATION NAME] therapy. 1. On 2/12/13 at 10:00 AM, a physician's order was received for Vitamin K 10 milligram (mg) subcutaneous injection (sq) times one now. (Vitamin K was ordered for high INR to assist with blood clotting). Transfer to the Long term Acute Care (LTAC, a sub-acute care hospital) facility for transfusion of 4 units Fresh Frozen Plasma.On 2/13/13 at 10:45 AM, a physician's order was received to discontinue Vitamin K 10 mg sq times one now. Vitamin K 10 mg orally times one now for INR (International normalized ratio a test for blood clotting) of 8.0. (Normal range for an INR 0.8 to 1.2. Note: If the INR gets too high it is taking too long for your blood to clot). A Nurses notes dated 2/12/13 at 1:00 PM, documented the [MEDICATION NAME] time (PT) and INR test results were relayed to the physician. An order was received for Vitamin K 10 milligram (mg) orally times one now and for the resident to be transferred to the LTAC for transfusion of four units of FFP (Fresh Frozen Plasma). The Vitamin K had been administered per orders and "awaiting for bed @ LTAC facility." The resident had no signs of active bleeding. The clinical record lacked documented evidence Resident #14 had been re- assessed after the entry into the nurses notes on 2/12/13 at 1:00 PM, until the entry 2/12/13 at 9:30 PM. On 2/12/13 at 9:30 PM, a nurses note documented the resident was in bed, asleep and responsive. The right upper arm Peripherally Inserted Central Catheter (PICC) line was intact and patent with intravenous fluids ongoing as ordered. On 2/13/13, 12:01 AM, the Licensed Nurse (LN) was called by the Certified Nursing Assistant (CNA). Resident #14's oxygen saturation level was 75% (A normal oxygen saturation level is between 95% to 100%) with oxygen at 3 liters per minute via nasal cannula. The resident was medicated with a Small Volume Nebulizer (SVN) treatment of [REDACTED]. Lungs clear to auscultation (listening to lung sounds). "Resident observed Mental status is altered." Vital signs blood pressure 97/54, respiratory rate 20, pulse rate 70, temperature 96.7 degrees Fahrenheit. (Note: Normal body temperature can range from 97.8? F to 99? F for a healthy adult. The normal pulse for healthy adults ranges from 60 to 100 beats per minute, Normal respiration rates for an adult person at rest range from 15 to 20 breaths per minute and guidelines now define normal blood pressure as follows: Less than 120 mm Hg systolic pressure and Less than 80 millimeters of mercury (mm Hg) diastolic pressure.) Oxygen saturation was 82-85% on "Non Rebreathing mask." Call to the physician and order was received to transfer the resident to the hospital for further evaluation. "911 Medical ambulance came and took over." Spoke with resident representative. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The back of the MAR indicated [REDACTED]. On 2/13/13 at 12:15 AM, a physician's order was received to transfer Resident #14 to the acute care hospital emergency room related to altered mental status and decreased oxygen saturation of 82%-85% on non "re-breathing mask." The clinical record lacked documented evidence the physician had been notified the resident was "awaiting" a bed at a LTAC. The clinical record lacked documented evidence as to why the resident had not been transferred to the LTAC in accordance with the physician's order received on 2/12/13 at 10:00 AM to receive the of 4 units Fresh Frozen Plasma. On 8/28/13 at 2:35 PM, a Licensed Nurse was not able to locate documentation on the February 2013 MAR indicated [REDACTED]. The Licensed Nurse verbalized if the as needed medication was administered the nurse would document on the back of the MAR indicated [REDACTED]. On 8/28/13 at 2:40 PM, a Licensed Nurse (LN) verbalized Resident #14 had an INR of 8.0 and the Vitamin K was administered as ordered. The LN verbalized the FFP would be used to decrease the bleeding time. The LN revealed with just the INR results "it doesn't paint a good picture " of want was going on with the resident. The LN indicated it was not clear why the order for FFP and transfer had not been done. The LN verbalized if a bed was not available or the physician's order was canceled, the staff should document why the physician's order was not followed. The LN confirmed there was no documentation to show why the transfer had not occurred. The emergency room report dated 2/13/13 documented Resident #14 had been seen in the emergency room (ER) at 1:02 AM. The resident had arrived by ambulance. The documentation revealed the altered mental status started today and was still present. "It was gradual in onset and has been constant." The resident had been disoriented and confused and was described as having decreased responsiveness. The resident was usually alert and orientated times three. The ER report documented the vitals signs were blood pressure 60/ palpable, heart rate 58, respiratory rate 24, oxygen saturation; unable to obtain due to the resident's condition. Skin deep sacral pressure ulcer with necrosis (bilateral buttocks). Necrotic toes to left foot and right above the knee amputation. The resident was disoriented. The ER report documented Resident #14 was intubated at 2:23 AM on 2/13/13 and placed on a ventilator. The report reveled the resident had a urinary tract infection and deep decubitus sacral ulceration with surrounding [DIAGNOSES REDACTED]. Disposition: admitted to the ICU (Intensive Care Unit) in Condition Critical Clinical Impression:[MEDICAL CONDITIONS], Urinary Tract Infection, [MEDICAL CONDITION], Pressure ulcer stage unspecified and Ischemic limb. The History and Physical (H&P) from the acute care hospital indicated Resident #14 been admitted on [DATE]. The H&P documented the resident was sent to the acute care hospital for altered mental status and appeared to be unresponsive and arrived with Emergency Medical Service (EMS). The resident was found to be significantly tachypneic (rapid respirations) with diminishing oxygen saturations. The resident was intubated and a chest x-ray showed bibasilar atelectasis and lab results indicated acute [MEDICAL CONDITION]. The resident presented with a significantly low blood pressure requiring multiple vasopressor support. The resident had a significant coccygeal stage 3 decubitus and well as a possible gangrenous left lower extremity toes. Documentation received from the facility entitled Documentation of Resident's Health Status, Needs and Service dated 10/31/09, revealed, the resident's medical record was a continuing account of the resident's health status and needs, the treatments delivered, results of diagnostic tests and the resident's response to treatment. The Interdisciplinary Team involved in the care of the resident was responsible for recording assessments of a resident's condition, changes in the resident's condition, a detailed accounting of interventions and an evaluation of the resident's progress toward established outcomes. Record pertinent resident data that may include but not limited to: a. Change of condition illness and ongoing monitoring b. Selected subjective data that validates or clarifies c. Action taken d. Notification of physician (name and status) e. Notification of family (name and relation to resident) f. Results of labs and follow-up g. Consultations h. Any unusual or abnormal occurrence i. All telephone calls made or received that are related to the resident j. Refusals, noncompliance, behavior occurrences k. Events and accidents document the details of the event, action taken, notifications, monitoring, and follow-ups. 2. The clinical record lacked documented evidence a physician's order had been obtained for the use of oxygen at 3 liters per nasal cannula or oxygen via a non breathing mask. On 8/28/13 at 10:35 AM, a Licensed Nurse (LN) verbalized a physician's order was required for the use of oxygen. On 8/28/13 at 1:50 PM, a LN confirmed the clinical record lacked documented evidence a physician's order had been received for the use of oxygen at 3 liters per nasal cannula or oxygen via a non re-breather mask. 2. Documentation from the facility entitled Fluid Intake & Output Measurement dated 10/31/06, reveled Intake and Output (I&O) measurement was recorded for residents according to the following criteria: -Residents identified as high risk for dehydration. -Residents with a physician's order for I&O. -Residents with a physician's order for fluid restriction -Residents with indwelling catheters (output only). -residents on intravenous therapy. The document defined fluid intake as all fluid entering the resident's body, including beverages, food that were liquid at room temperature such as flavored gelatin, custard and ice cream. The definition of output revealed all fluid that left the body such as urine, loose stools, emesis. According to the document entitled, Fluid Intake & Output Measurement the documentation guidelines were to record the shift, type and amount of both intake and output. On 2/10/13 a physician's order was received for Resident #14's Intake and Output (I&O) every shift. The clinical record lacked documented evidence Resident #14's oral intake and output had been monitored/ documented on 2/10/13, 2/11/13, 2/12/13 and 2/13/13 in accordance with the physician's orders. On 8/28/13 at 10:35 AM, a Licensed Nurse (LN) verbalized if a physician ordered I&O the information would be documented on the I&O flow sheet. The documentation would contain a resident's intake of fluids, and documentation of the resident's output of urine and emesis. On 8/28/13 at 1:50 PM, a LN confirmed the clinical record lacked documented evidence I&O's were done in accordance with the physician's order. 3. On 2/10/13 a physician's order was received to obtain stool for [MEDICAL CONDITIONS], Norovirus and Ova and Parasite. Resident #14's clinical record contained laboratory test results for the Norovirsus and Ova and Parasites. The clinical record lacked documented evidence of laboratory test results for [MEDICAL CONDITION] in accordance with the physician's orders. On 8/28/13 at 1:50 PM, a LN confirmed the clinical record lacked documented evidence a laboratory specimen had been tested for [MEDICAL CONDITION] in accordance with the physician's order. 4. On 2/10/13 a physician's order was received for Resident #14 to have a hospice evaluation. The clinical record lacked documented evidence the hospice evaluation had been arranged or completed in accordance with the physician's order. On 8/28/13 at 1:50 PM, a LN confirmed the clinical record lacked documented evidence a hospice evaluation had been done in accordance with the physician's order Resident #9 Resident #9 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was also on [MEDICAL TREATMENT] three times a week. 1. Physician's order (dated 7/13/13) to float heels while in bed for every shift: Nursing staff failed to follow physician's orders to float the resident's heels while in bed. The resident was observed on the following days with both heels touching the mattress while lying in bed: 8/28/13, 8/29/13 and 8/30/13. On 8/28/13, at 10:30 AM, the resident was observed with his heels against the mattress. On 8/29/13, at 8:30 AM, the resident was observed with a pillow between his knees and both heels resting against his mattress. On 8/30/13. at 2:30 PM, the resident was observed with his heels against his mattress. On 8/29/13, Employee #12 was interviewed and stated that is was the registered nurses' responsibility to assess the resident and relay the orders to the CNA (certified nursing assistant). On 8/30/13, the resident was interviewed and was unable to recall the staff taking special precautions to make sure that his heels were not touching the mattress. 2. Nursing staff did not follow [MEDICAL TREATMENT] recommendations and physician's orders to follow fluid restrictions. A review of [MEDICAL TREATMENT] Communication Records indicated: On 8/3/13, a recommendation was made to limit the resident's fluid intake to 48 ounces per day. On 8/6/13, a recommendation was made to limit fluid intake because resident was gaining 5-6 kilograms between [MEDICAL TREATMENT] treatments and that he should only be gaining 1 -2 kilograms. On 8/20/13, a recommendation was made to limit fluid intake to 40 ounces per day because he was gaining 5-6 liters in between treatments. A review of doctor orders did not indicate that the recommendations had been relayed to the physician. There were no new fluid restriction orders in the file after 7/30/13. A review of the resident's Comprehensive Intake-Output Record (I&O) record showed that the resident had gone over the recommended fluid restriction on the following days: On 8/22/13, the resident received a total of 1520 milliliters (ml) of fluids for the day. On 8/23/13, the resident received a total of 1540 ml of fluids for the day. On 8/25/13, the resident received a total of 1620 ml of fluids for the day. An interview with Employee #5; who was assigned to Resident #9's care on 8/30/13, revealed that she was unaware of the resident's fluid restriction and that she was not informed by the nursing staff of the resident's fluid restrictions. She stated that as far as she knew, Resident #9 could "drink as much as he wanted". 3. On 7/14/13, the resident's physician had ordered the following labs to be drawn on the morning of 7/15/13: a complete blood count (CBC) and a basic metabolic panel (BMP). When interviewed on 8/29/13, Employee #12 was unable to locate the lab work in the resident's file. 4. On 8/22/13, the resident's physician had ordered the following labs to be drawn on the morning of 8/23/13: a CBC, BMP and liver function test. The labs were not drawn until 8/24/13. 5. A review of Resident #9's Treatment Administration Record (TAR) dated 7/13/13, indicated that the resident had a wound on his right foot, left foot, right hip and right lower ribs. A wound care consult and treatment was ordered by the resident's physician on 7/14/13. When interviewed on 8/29/13, Employee #12 was unable to locate the results of the wound care consult in the resident's file. Resident #3 Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/28/13 in the afternoon, the Registered Nurse (RN) administered [MEDICATION NAME] 0.1 mg (milligrams) through the residents gastrostomy tube. Resident #3's physician orders indicated to hold [MEDICATION NAME] 0.1 mg if the heart rate was below 60 beats a minute. The RN did not take Resident #3's heart rate prior to administering the medication. On 8/29/13 in the morning, the RN confirmed Resident #3's heart rate was not taken prior to administering [MEDICATION NAME] 0.1 mg and the orders were not followed.