Every finding on record at Life Care Center of las Vegas

Based on interview, record review, and document review, the facility failed to protect residents from ongoing and repeated sexual and/or physical contact by a cognitively impaired resident with a history of continued repeated behaviors for 1 of 6 sampled residents (Resident 2) and 3 of 3 unsampled residents (Resident 7, 8, and 9). The deficient practice placed the residents at risk for continued nonconsensual physical contact and potential psychosocial distress.Findings include:Resident 2 (R2) was admitted [DATE], with diagnosis including dementia unspecified severity with anxiety/psychotic disturbance, depression, and adult failure to thrive.On 05/13/2026 at 1:17 PM, R2 was observed in the hallway seated in a wheelchair holding a stuffed animal. R2 looked toward the surveyor, immediately looked away, and did not acknowledge the surveyor's greeting. R2 did not interact with the surveyor and did not respond to questions. R2 was observed calm.A Minimum Data Set assessment dated [DATE], documented R2's cognitive skills were severely impaired. A Care Plan dated 11/20/2025 documented dementia and related concerns including behavior and communication deficit.A Care Plan dated 04/22/2026 included dementia, R2 was confused and very forgetful. R2 had communication deficits, and was rarely understood and sometimes understood, related to dementia. The care plan documented a resident-to-resident sexual altercation on 01/18/2026. A Facility Reported Incident Report documented on 01/18/2026 a male resident grabbed R2's right breast. On 01/19/2026 a (Late Entry) Health Status Note, documented on 01/18/2026 at 1:40 PM, it was reported by staff R2 was seen with a male resident in the hallway, having inappropriate touching behavior towards R2. Both residents were separated. R2's chest was assessed in R2's room, with no redness or bruises noted.Medical record review identified Resident 1 (R1) as the male resident involved in the documented incident with R2.On 05/13/2026 at 1:24 PM, a Social Worker, during discussion of the incident between R2 and R1 on 01/18/2026, reported there had been no other incidents of that kind involving R1.On 05/13/2026 at 1:30 PM, the Abuse Coordinator, during discussion of the incident between R2 and R1 on 01/18/2026, reported no other sexual behavior was identified with R1 after the incident. The Abuse Coordinator reported there was only one incident of sexual behavior with R1. Record review identified three additional documented incidents of sexual and/or physical behaviors by R1, following the incident of 01/18/2026, involving three separate female residents including:Resident 7 (R7) was admitted [DATE], with diagnoses including major depressive disorder recurrent, personal history of traumatic brain injury, and post-traumatic stress disorder.On 05/14/2026 at 3:24 PM, R7 denied any incidents of unwanted physical contact involving residents or staff.On 05/14/2026 at 12:45 PM, the Activities Director and the Abuse Coordinator reported R7 was involved in a documented incident with Resident 1 (R1) on 04/23/2026. Review of R1's medical record revealed R1 approached R7 in the hallway, encroached in R7's space, R1 placed a hand on R7's knee and triggered R7 to yell for help to get R1 away from self.Resident 8 (R8) was admitted [DATE], with diagnosis including Alzheimer's disease, dementia unspecified severity with psychotic disturbance, and altered mental status.On 05/14/2026 at 3:28 PM, R8 did not speak or engage in conversation. R8 made gentle nodding motions intermittently, however, no clear acknowledgment or response to questions was observed. The Activities Director explained R8 was non-verbal.A Minimum Data Set assessment dated [DATE], documented cognitive skills severely impaired. On 05/14/2026 at 12:45 PM, the Activities Director and the Abuse Coordinator reported R8 was involved in a documented incident with Resident 1 (R1) on 04/26/2026. Review of R1's medical record revealed R1 wheeled self next to R8, encroached into R8's space, placed a hand and rubbed R8's knee/leg.Resident 9 (R9) was admitted [DATE], with diagnoses including dementia unspecified severity with agitation, cognitive communication deficit, and depression.On 05/14/2026 at 3:38 PM, R9 reported being unable to recall an incident involving another resident attempting to touch R9 in an unwanted manner.A Minimum Data Set assessment dated [DATE], documented R9 had severe cognitive impairment.On 05/14/2026 at 12:45 PM, the Activities Director and the Abuse Coordinator reported R9 was involved in a documented incident with Resident 1 (R1) on 05/05/2026. R1 rolled self at a fast pace to 100 hall, grabbed R9 by the hand, and triggered R9 to curse and yell at him.Resident 1 (R1) was admitted [DATE], with diagnoses including metabolic encephalopathy, and other specified anxiety disorders.On 05/13/2026 at 9:29 AM, R1 was observed in bed lying in bed. R1 opened their eyes, lifted head and nodded yes to their name being called. R1 did not engage in conversation, looked away and closed their eyes.On 05/14/2026 at 3:33 PM, R1 was lying in bed with a blanket covering their face. R1 responded to greeting by sitting up in bed and repeatedly said thank you. R1 did not answer any questions, laid back down in bed and covered their head with a blanket.A Minimum Data Set assessment dated [DATE] documented R1's cognitive skills were severely impaired.A Behavior Note dated 10/18/2025, documented R1 exhibited sexually aggressive verbal and physical behavior towards staff. Additional record review revealed this entry was the initial documented occurrence of aggressive sexual and physical behaviors, followed by continued documented sexual and/or physical behaviors throughout R1's medical record.A Care Plan revised 11/17/2025, documented R1 had the potential of verbal aggression and inappropriate sexual behaviors towards staff, related to dementia.A Care Plan dated 01/18/2026, documented R1 had an incident of touching a female resident inappropriately.On 01/18/2026 a Facility Reported Incident report documented R1 grabbed a female resident's right breast.Additional record review for R1 revealed 12 additional documented incidents of sexual and/or physical behaviors exhibited by R1 involving staff from 03/05/2026 through 05/05/2026.The medical record lacked documented evidence interventions were reassessed, revised, or evaluated for effectiveness despite R1's continued behaviors.On 05/14/2026 at 3:30 PM, a Certified Nursing Assistant (CNA) stated R1 was not like this before. The CNA reported the resident did not previously display sexual and physical behaviors and described the behaviors as new.On 05/14/2026 in the afternoon, a Licensed Practical Nurse (LPN) and a Unit Care Coordinator, explained R1 was able to wheel around independently. The LPN reported resident showed behavior with staff and acknowledged some of the incidents documented in the medical record involved female residents.On 05/14/2026 at 12:28 PM during a telephone interview, a Psychiatric Nurse Practitioner (APRN), reported providing medication management, including non-pharmacological interventions for R1. The APRN indicated R1 was prescribed Hydroxyzine for anxiety. The APRN verbalized they could not medicate the behaviors out of the resident and the facility was responsible for monitoring R1 and implementing interventions. The APRN did not answer questions regarding their approach for R1's continued behaviors and directed the surveyor to read the APRN's notes.On 05/14/2026 at 12:45 PM, in a joint interview with the Activities Director and the Abuse Coordinator, the Activities Director described the incidents with R1 and three female residents on 04/22/2026, 04/26/2026 and 05/05/2026. The Activities Director reported the incidents were not reported to the state agency. The Abuse Coordinator explained the incidents were deemed not reportable in part due to the immediate response of the staff to separate residents. The Activities Director explained not all incidents of this nature would be reported to the psychiatric provider, as the psychiatric provider could independently search R1's medical record for information regarding incidents and behavior.On 05/14/2026 at 4:36 PM, the Abuse Coordinator reported the process of abuse coordination started upon hire at staff orientation. The Abuse Coordinator explained requested all staff who witnessed abuse call the Abuse Coordinator directly and reported Social Services as well as the Unit Managers worked hand in hand to investigate abuse.A facility policy titled Abuse Prevention revised 04/01/2026, documented it was the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident, and exploitation. Identify, correct, and intervene in situations in which abuse, neglect, exploitation, and or misappropriation of resident property is more likely to occur.

Based on interview, record review, and document review, the facility failed to reassess, revise, or reevaluate the effectiveness of care plan interventions, despite continued sexual and/or physical behaviors for 1 of 6 sampled residents (Resident 1). The deficient practice had potential to result in ineffective management of continued sexual and physical intrusive behaviors.Findings include:Resident 1 (R1) was admitted [DATE], with diagnosis including metabolic encephalopathy, and other specified anxiety disorders.On 05/13/2026 at 9:29 AM, R1 was observed in bed lying in bed. R1 opened their eyes, lifted their head, and nodded yes to their name being called. R1 did not engage in conversation, looked away and closed eyes.On 05/14/2026 at 3:33 PM, R1 was lying in bed with blanket covering their face. R1 responded to greeting by sitting up in bed and repeatedly said thank you. R1 did not answer any questions, laid back down in bed and covered their head with a blanket.A Minimum Data Set assessment dated [DATE] documented R1's cognitive skills were severely impaired.A review of R1's medical record revealed four documented incidents of sexual and/or physical behaviors involving female residents, as well as 12 additional documented incidents of sexual and or physical behaviors exhibited by R1 involving staff from 01/18/2026 through 05/05/2026.A Care Plan dated 01/18/2026, documented R1 had an incident of touching a female resident inappropriately with goals and interventions listed. The Care Plan documented a revision date of 04/02/2026, entered by a Licensed Practical Nurse (LPN). The Care Plan lacked documented evidence interventions were revised or updated despite the document revision date of 04/02/2026.On 05/14/2026 at 12:28 PM during a telephone interview, a Psychiatric Nurse Practitioner (APRN), reported providing medication management including non-pharmacological interventions for R1. The APRN stated the facility was responsible for monitoring R1 and implementing interventions.On 05/14/2026 at 1:43 PM, a Licensed Practical Nurse (LPN) explained the LPN's responsibilities included revising and updating resident care plan interventions when changes were identified. The LPN confirmed entering R1's care plan revision dated 04/02/2026 and acknowledged a revision date was entered on R1's care plan, however, no interventions were added, revised or updated. The LPN was unable to explain why the revision date was entered without documented intervention changes and confirmed revision entry should have reflected intervention changes. On 05/12/2026 at 1:43 PM, the Executive Director (ED) explained care plan revisions occurred when changes to care or interventions were identified. The ED confirmed a revision date of 04/02/2026 was entered on R1's care plan without documented changes or updates to the interventions. The ED reported additional interventions had been identified for R1, including increased staffing for resident monitoring in the halls and to move the resident to a specific area following meals. The ED acknowledged the new interventions had not been added to the care plan. The ED stated the interventions may have been missed when care plan revision date was entered and confirmed the interventions should have been updated and included in R1's care plan.R1's care plan lacked documented evidence of new or updated interventions related to R1's continued sexual and physical intrusive behaviors since 01/21/2026, including increased staffing for resident monitoring in the halls and moving the resident to a specific area following meals. R1's care plan lacked documented evidence existing interventions had been reassessed or reevaluated for effectiveness.A facility policy titled Comprehensive Care Plans and Revisions reviewed 08/29/2025, documented the facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to the care delivery, this can include additional interventions or existing problems and updating goal or problem statements.

Based on interview, record review, and document review, the facility failed to implement, and accurately complete physician ordered behavior monitoring for agitation, sexual behavior, interventions, and outcomes for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential to result in failure to identify, monitor, and manage continued sexual and physical behaviors.Findings include:Resident 1 (R1) was admitted [DATE], with diagnosis including metabolic encephalopathy, and other specified anxiety disorders.On 05/13/2026 at 9:29 AM, R1 was observed in bed lying in bed. R1 opened their eyes, lifted their head, and nodded yes to their name being called. R1 did not engage in conversation, looked away and closed eyes.On 05/14/2026 at 3:33 PM, R1 was lying in bed with blanket covering their face. R1 responded to greeting by sitting up in bed and repeatedly said thank you. R1 did not answer any questions, laid back down in bed and covered their head with a blanket.A Minimum Data Set assessment dated [DATE] documented R1's cognitive skills were severely impaired.A physician order dated 11/17/2025, documented to monitor behavior exhibited including agitation and inappropriate sexual behavior, along with interventions, instructions to chart to progress notes every shift, monitor number of behavior episodes, and outcome including improved, worsened or unchanged.A review of R1's medical record revealed 14 incidents of sexual and/or physical behavior exhibited by R1 between 03/05/2026 and 05/05/2026.A review of R1's Medication Administration Record (MAR) from 03/01/2026 through 05/13/2026 lacked documented evidence behaviors, interventions, and outcomes were monitored for 12 of the14 incidents. The MAR documented zero or not applicable.A Behavior Monitoring and Interventions Report dated 03/01/2026 through 05/14/2026 lacked documented evidence behaviors and interventions were monitored for 13 of the 14 incidents. The Behavior Monitoring and Interventions Report documented No behaviors Observed.On 05/14/2026 at 12:28 PM, a Psychiatric Nurse Practitioner (APRN), reported providing medication management including non-pharmacological interventions for R1. The APRN indicated the facility was responsible for monitoring R1 and implementing interventions.On 05/13/2026 at 1:30 PM, Executive Director (ED) reported monitoring new behaviors, changes, and redirections for R1 were discussed in facility rounds. R1 would continue to be monitored and interventions would be implemented.On 05/14/2026 at 3:12 PM, a Licensed Practical Nurse (LPN), reported familiarity with R1. The LPN explained when a physician order for behavior monitoring was in place, the electronic medical record prompted monitoring for residents. The LPN explained staff were to click on the prompt and answer yes or no to document whether behaviors were observed, as well as interventions performed and whether interventions were effective. The LPN reported the purpose for behavior monitoring was to assist physicians in creating or updating treatment plans. The LPN acknowledged monitoring should have been completed for R1 to accurately reflect the behaviors because it was an important part of resident care.On 05/14/2026 at 4:36 PM, the ED confirmed behavior monitoring was not completed for the R1 on the reviewed incident dates. The ED explained since the resident was monitored in other ways, staff may not have entered behavior under the behavior monitoring task. The ED confirmed staff should have monitored and documented behaviors on the behavior monitoring task. The ED reported behavior monitoring helped identify behavior triggers, trends, effectiveness of interventions, possible changes to medication, whether the interventions were effective, and whether the behavior continued to occur. A facility policy titled Abuse Prevention reviewed 04/01/2026, documented to identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as verbally, physically, and sexually aggressive behaviors.A facility policy titled Clinical Leadership Resource Pathway, Area of Focus: Behavior Management reviewed 12/01/2025, documented the facility would monitor the residents closely including expressions or indications of distress, and accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record.

Based on observation, interview, record review and document review, the facility failed to ensure a care plan intervention to provide one-on-one (1:1) feeding assistance for a resident who was assessed to be at risk for malnutrition was implemented for 1 of 40 sampled residents (Resident 19). The deficient practice had the potential to place the resident at an increased risk for malnutrition.Findings include:Resident 19 (R19) was admitted on [DATE] with diagnoses including hepatic encephalopathy, protein calorie malnutrition and altered mental status. On 01/07/2026 at 8:07 AM, R19 was seated in a chair by the bedside eating slowly and independently. R19's breakfast meal included scrambled eggs, bacon strips and milk. There were no staff members nearby or inside R19's room.A physician order dated 10/16/2025, documented to provide 1:1 feeding assistance. On 01/07/2026 at 8:24 AM, the Registered Nurse (RN) confirmed R19 had a care plan intervention to provide 1:1 feeding assistance as determined by the inter-disciplinary (IDT) team due to weight loss and poor meal intakes. The RN confirmed R19 was eating alone in the room with no staff present. The RN stated R19 did not have swallowing difficulties but had poor meal intakes which was why the resident was placed on 1:1 feeding. The RN confirmed R19's care plan was not followed.On 01/07/2026 at 8:26 AM, a Certified Nursing Assistant (CNA) indicated being steadily assigned to R19. The CNA stated R19 did not require feeding assistance but set up for meals and occasional supervision since R19 was able to eat independently. The CNA explained 1:1 feeding assistance meant staff needed to be with the resident from set up to meal completion while actively feeding the resident. The CNA was not aware R19 had a care plan intervention for 1:1 feeding assistance.On 01/07/2026 at 8:48 AM, the Registered Dietitian (RD) explained the dietary team was closely monitoring R19 due to a history of significant weight loss. The RD stated R19 was to be provided with 1:1 feeding assistance for all meals even if recent weights were stable, the meal intakes had improved, and body mass index (BMI) went up to 14.5 because R19 was still underweight. The RD indicated this was the first time the dietary team learned the CNA steadily assigned to R19 was not providing 1:1 feeding assistance but set up assistance.On 01/07/2026 at 8:55 AM, the RD confirmed R19's care plan intervention to provide 1:1 feeding assistance was not implemented.The comprehensive care plan policy reviewed 08/29/2025, documented the facility monitored the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered care plan.The Person-Centered Care Planning revised 08/29/2025, documented the facility developed a person-centered care plan to attain or maintain the resident's highest practicable well-being and prevent avoidable decline. The care plan was developed and implemented to ensure consistency across all shifts.

Based on observation, interview, record review and document review, the facility failed to ensure physician orders were followed to provide one-on-one (1:1) feeding assistance for a resident assessed to be at risk for malnutrition for 1 of 40 sampled residents (Resident 19). The deficient practice had the potential to place the resident at an increased risk for malnutrition.Findings include: Resident 19 (R19) was admitted on [DATE] with diagnoses including hepatic encephalopathy, protein calorie malnutrition and altered mental status. On 01/06/2026 in the morning, R19 responded with nonsensical speech (used words, phrases with no meaning). R19 had a gaunt face (appearing thin, bony and hollow with sunken cheeks).On 01/07/2026 at 8:07 AM, R19 was seated in a chair by their bedside eating breakfast slowly and independently. The breakfast meal included scrambled eggs, bacon strips and milk. There were no staff members nearby or inside R19's room one-on-one (1:1) feeding assistance with the meal.R19's meal ticket indicated R19 was on a regular diet, regular texture and thin liquids with beverage of choice.A physician order dated 10/16/2025, documented to provide 1:1 feeding assistance. On 01/07/2026 at 8:24 AM, the Registered Nurse (RN) confirmed personally entering R19's orders for 1:1 feeding assistance on 10/16/2025 after attending the inter-disciplinary (IDT) team which determined R19 would have benefited from 1:1 feeding assistance due to weight loss and poor meal intakes. The RN confirmed R19 was eating alone in room with no staff present. The RN stated R19 did not have swallowing difficulties but had poor meal intakes which was why the resident was placed on 1:1 feeding. The RN emphasized the order for 1:1 feeding assistance was active and had not been discontinued.On 01/07/2026 at 8:26 AM, a Certified Nursing Assistant (CNA) indicated being steadily assigned to R19. The CNA stated R19 did not require feeding assistance but meal setup and occasional supervision since R19 was able to eat independently. The CNA explained 1:1 feeding assistance meant staff needed to be with the resident from set up to meal completion while actively feeding the resident. The CNA was not aware R19 had a care plan intervention for 1:1 feeding assistance and acknowledged this order was not followed.A nutrition note dated 10/08/2026, documented R19 had a significant weight loss of five pounds or 5.1 percent (%), over 30 days. Average meal intakes ranged from 47% to 75%. New interventions included nutritional treat with meals, Med pass (a dietary supplement) twice daily and Megace (an appetite stimulant).A nutrition note dated 10/22/2026, documented R19 had a significant weight loss of three-pound or 3.2 %, over seven days. Average meal intakes ranged from 53% to 76%. New interventions included 1:1 feeding assistance initiated on 10/16/2025 to promote adequate meal intake.A change of condition note dated 11/18/2025, R19 had a significant weight loss of 26 pounds or 23 %, over 180 days. R19 weighed 87 pounds and had a body mass index (BMI) of 14.0 (normal range: 18 to 25). R19 was underweight related to decreased caloric intake.On 01/07/2026 at 8:48 AM, the Registered Dietitian (RD) explained the dietary team was closely monitoring R19 due to a history of significant weight loss. The RD stated R19 was to be provided with 1:1 feeding assistance for all meals even if recent weights were stable, the meal intakes had improved, and BMI went up to 14.5 because R19 was still considered underweight. The RD indicated this was the first time the dietary team learned the CNA steadily assigned to R19 was not providing 1:1 feeding assistance but set up assistance.On 01/07/2026 at 8:55 AM, the RD verbalized 19 should continue to receive 1:1 feeding assistance which was still an active order.The Feeding a Resident policy revised 07/17/2021, documented a resident who was unable to carry out activities of daily living (ADLs) would receive necessary services to maintain good nutrition, based on the comprehensive assessment.

Based on observation, interview, record review, document review, the facility failed to ensure information gathered by hospice staff related to the resident's hospice recertification reflected the improving nutritional status for a resident with a primary hospice diagnosis of protein-calorie malnutrition for 1 of 40 sampled residents (Resident 177). The deficient practice had the potential to deprive the resident of a higher level of medical care outside hospice services. Findings include:Resident 177 (R177) was admitted on [DATE] and readmitted on [DATE], with diagnoses including protein-calorie malnutrition and hospice status.The Hospice-Nursing Facility Agreement signed 10/01/2025, documented hospice and facility shall communicate with one another regularly and as needed for each hospice resident. Each party was responsible for documenting such communications in its respective clinical record. On 01/07/2026 at 8:02 AM, a certified nursing assistant (CNA) was observed providing feeding assistance to R177. The breakfast meal included scrambled eggs, bacon strips, milk, fortified cereal, and vanilla ice cream. During the meal, R177 told the CNA, More bacon. On 01/07/2026 at 8:04 AM, the CNA stated R177 had consumed 100 percent (%) of the breakfast meal and was finishing the vanilla ice cream. The CNA indicated R177 was a hospice resident and required one-on-one (1:1) feeding assistance due to malnutrition. The CNA explained R177's meal intake varied but lately the resident had been consuming 100% of most meals.On 01/07/2026 at 2:27 PM, R177 with clear speech R177 asked the surveyor for a snack because R177 was hungry. A CNA who was closely behind responded that a sandwich had been requested from the kitchen and was on its way. A certification of terminal illness (CTI) revealed R177 was enrolled into the hospice program for period 09/29/2025 to 12/27/2025 with a primary diagnosis of protein-calorie malnutrition. On 01/07/2026 at 2:28 PM, a Licensed Practical Nurse (LPN) assigned to R177 indicated the resident was recertified by the hospice provider on 12/28/2025 and a copy of the updated CTI had been requested from the hospice provider.A quarterly nutrition data collection completed on 12/30/2025, referenced an inter-disciplinary (IDT) team meeting held on 12/03/2025 which revealed R177 had a weight gain of five pounds or a 5.4 percent (%) over a 30-day period. R177 weighed 93 pounds on 11/03/2025 and 98 pounds on 12/02/2025. Average meal intakes were 64% to 85% each meal. The weight gain was considered significant, beneficial and planned.On 01/08/2026 at 11:00 AM, the Director of Clinical Operations (DCO) for the hospice provider indicated R177 was admitted into the hospice program on 07/01/2025 with a primary diagnosis of protein- calorie malnutrition. A hospice nurse practitioner (NP) had a face-to-face encounter with R177 on 12/18/2025 for the purpose of upcoming recertification for the third benefit period beginning 12/28/2025.On 01/08/2026 at 11:10 PM, the DCO indicated R177 was recertified for the third benefit period due to information gathered by the hospice NP which revealed R177 had poor appetite and was consuming one meal a day at 50% to 100%. R177 was experiencing weight loss, appeared cachectic (wasting syndrome), was in decline and only spoke in one or two words. R177 would continue to benefit from hospice services due to decline and was expected to continue to decline. On 01/08/2026 at 11:15 AM, the DCO indicated not being aware R177 had a significant weight gain of five pounds or 5.4 % identified by the IDT before the hospice NP's visit on 12/18/2025. The DCO indicated recorded meal consumptions by the facility indicated R177 was consuming 64% to 85% of each meal. A meal observation of R177 consuming 100% of the morning meal and a clear request for a snack in the afternoon did not align with the hospice NP's information. This resulted in the medical director's recertifying R177 for a new benefit period from 12/28/2025 to 02/25/2026. The DCO stated if the hospice nurse and NP gathered information pertinent to R177's diagnosis of protein-calorie malnutrition, there was a possibility the medical director may not have decided to recertify R177 into the hospice program.On 01/08/2026 at 11:30 AM, two nutrition coordinators indicated hospice staff had not reached out to the dietary team regarding R177's nutritional status.On 01/08/2026 at 11:40 AM, the Registered Dietitian (RD) indicated hospice staff had not reached out to the RD regarding R177's nutritional status.On 01/08/2026 at 12:22 PM, the Director of Nursing (DON) confirmed the hospice visit note dated 12/18/2025 was for the purpose of R177's recertification for a new benefit period. The DON confirmed R177 had significant weight gain of 5.4% from 11/03/2025 to 12/01/2025, and this information was available to hospice personnel prior to the face-to-face encounter by the hospice NP. The DON expected the hospice personnel to gather information from the appropriate member of the IDT, which in this case should have been the nurses, the RD and the dietary team because they would have been more knowledgeable regarding the resident's nutritional status and whether it was improving or declining. On 01/08/2026 at 12:58 PM, the Executive Director (ED) indicated the hospice provider assumed primary oversight of residents under hospice care while the facility would provide room and board. The ED explained the agreement specified responsibilities of hospice and the facility along with proper coordination of care. According to the ED, based on the agreement the hospice and the facility were expected to communicate regularly, and each party was responsible for documenting communication in respective records. On 01/09/2026 at 11:10 AM, a hospice registered nurse (RN) indicated being employed by the hospice provider for four months and visited R177 once a week. The RN was not aware R177 had improved meal intakes because the RN was present for one lunch observation where R177 consumed only 50% of the meal. The RN indicated not being aware R177 had significant weight gain because the RN had not spoken to the dietary team.The facility's hospice coordination of care policy (revised 09/03/2025) documented hospice care was provided under a written agreement. Hospice representatives coordinated with facility staff during care planning. The facility communicated with the hospice medical director, attending physicians, and other practitioners, and obtained the following: hospice plan of care, hospice election form, physician certification/recertification of terminal illness, and physician's orders.

Based on observation, interview, and document review, the facility failed to ensure stored foods were stored properly and ice machines were properly cleaned for 3 of 5 ice makers in the facility. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness. Findings include: On 11/19/2024 in the morning, there was an open bottle containing blackberry sauce in the dry food storage area with an expiration date of June 10, 2024. The Dietary Director explained the blackberry sauce should have been discarded. On 09/04/2024 in the morning, there was an ice machine in the kitchen with brownish spots on the inner ice shield, debris buildup on the metal lip between the lid and the opening of the ice chamber, and debris buildup of the front grill covering the filter of the ice machine. There was an ice machine in the 300-hall nourishment room with a debris buildup on the ice spout of the machine. There was another ice machine in the 400-hall nourishment room with a debris buildup on the ice spout of the machine. The Dietary Director explained the ice machines are cleaned periodically and were recently cleaned. On 11/22/2024 in the afternoon, the nourishment room ice machines were inspected again showing debris buildup on the ice spout of the 300 and 400 hall machines. A facility document titled Ice Machines revised 06/12/2023, revealed ice machines should be maintained in a clean and sanitary state following infection prevention and control guidelines. A facility document titled Food Safety revised 04/26/2023 revealed under dry storage, opened packages of food are resealed tightly to prevent contamination of the food item and use by date will be used. Food not safe for consumption or if the safety of the food is in question, it will be removed from storage.

Based on clinical record review, document review and interview, the facility failed to ensure residents were provided information about the right to formulate an advanced directive for 2 of 31 sampled residents (Resident #74 and Resident #5). The deficient practice has the potential to deprive residents of their right for self-determination. Findings Include: Resident #74 (R74) R74 was admitted to the facility on [DATE], with diagnoses including Guillain-Barre Syndrome, multiple sclerosis, systemic lupus erythematosus, and unspecified dementia. R74's social services progress note dated 07/29/2024 documented the resident was alert and oriented times three and scored a 15/15 on the Brief Interview for Mental Status (BIMS) exam, meaning the resident is cognitively intact. The note also states the resident can make their own decisions. A resident document titled Physician Order for Life-Sustaining Treatment (POLST) dated 08/06/2018 was filled out by R74's ex-spouse as Do Not Attempt Resuscitation and was signed by the provider. On 11/20/2024 at 3:00pm, R74 revealed were unaware of what advanced directives were. Advanced directives were explained to the resident. R74 stated no one had talked to them about advanced directives until this day. R74 stated if something were to happen, the resident wanted the facility staff to attempt to resuscitate. Resident #5 (R5) R5 was originally admitted to the facility on [DATE], with diagnoses including aneurysm of artery of lower extremity, acute embolism and thrombosis of unspecified deep veins of left lower extremity, and peripheral vascular disease. R5's social services progress note dated 10/03/2024 documented the resident has aphasia and is nonverbal and unable to complete the Brief Interview for Mental Status (BIMS). Questions asked in yes or no format where the resident can use gestures of nodding of head were used. The resident does have difficulty making themself understood only using gestures and no other communication. R5 can use gestures to make concrete needs known. The note also states the resident can usually understand information but needs a little extra time to integrate information. A resident document titled Physician Order for Life-Sustaining Treatment (POLST) dated 12/02/2021 was filled out by R74's niece as Do Not Attempt Resuscitation and was signed by the provider. A resident document titled Admission Record (face sheet) documented the resident was the responsible party and the niece was the emergency contact. R5's medical record lacked documentation the resident gave permission for the niece to make medical decisions on their behalf or the niece was the power of attorney for healthcare or the guardian for the resident or the resident was incompetent to make decisions. On 11/20/2024 at 2:39 PM, the Director of Social Services acknowledged the resident had no other family or friends and the facility would first have to get a psychological evaluation to see if the resident is competent to make decisions regarding a power of attorney as the staff feel the resident has moderately impaired decision-making abilities. The facility policy titled, Advance Directives and Advanced Care Planning revised 08/02/2022, documented residents have the right to self-determination regarding their medical care. This includes the right of an individual to direct his or her own medical treatment, including the right to execute or refuse to execute an advanced directive. A resident who has not been declared incompetent has the right to designate a representative to exercise the residents' rights to the extent those rights are delegated to the representative. Each time the resident is admitted to the facility, quarterly, and when a change in condition is noted in the resident condition, the facility should review the advanced directive and advanced care planning information.

Based on interview, record review and document review, the facility failed to ensure the appropriate state mental health authority was notified promptly following a change in condition for 1 of 31 sampled residents (Resident #81). The deficient practice had the potential to deprive the resident of concern and other residents of necessary behavioral health services. Findings include: Resident 81 (R81) R81 was readmitted on [DATE], with diagnoses including schizoaffective disorder, unspecified dementia with behavioral disturbance, major depressive disorder, and bipolar disorder. On 11/19/2024 in the afternoon, R81 stated the pureed food was horrible and they rarely eat it. R81 stated had been back to the hospital a couple times since admitted to the facility. The resident had no issues with laundry and housekeeping, was receiving and happy with physical therapy, occupational therapy, and the nursing care. The resident indicated liked participating in the Activities Department events to get out of their room. R81 tended to jump from one thing to another randomly. A PASARR level one document dated 01/29/2020, revealed R81 did have the dementia diagnosis, however, no other mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility placement. A review of the resident's medical notes revealed R81's schizoaffective disorder was diagnosed on [DATE] and the resident's major depressive disorder was diagnosed on [DATE]. A review of the resident's physician progress notes on 3/29/2022 and 03/31/2022 revealed R81's bipolar disorder was diagnosed on these physician notes; however, it had not been added to the list of diagnoses in the Point Click Care (PCC) Medical Records System. A nurse's progress note dated 05/19/2024 at 08:55 AM, documented R81 was involved in a resident-to-resident altercation where R81 punched another resident in the face causing the other resident to lose a tooth. The note documented R81 stated they were hit first but had managed to knock the other resident's tooth out. Documentation revealed R81 was seen by psychiatric services within minutes of the incident and had given the order to complete a Legal Discharge for R81 to a psych ER for acute treatment. On 11/21/2024 at 9:30 AM, the Medical Records Director (MRD) acknowledged the resident diagnoses are entered by the medical records department. The MRD was not sure why the Bipolar Diagnosis had not been added since the physicians had diagnosed the disorder and the facility had been documenting this diagnosis in the resident's Modified Data Set (MDS). The MRD acknowledged the diagnosis should have been added to the residents list of Diagnoses in PCC. On 11/21/2024 at 10:10 AM, the Medicaid Eligibility Specialist (MES) explained was responsible for referring residents who met criteria for PASARR II by completing the PASARR referral in the PASARR system. When asked if a residents' diagnoses of schizoaffective disorder, major depressive disorder, and bipolar disorder would be representative of mental illness, intellectual disability, or a related condition which the Medicaid Service Manual documents a PASARR II must be completed for, the MES explained this was not necessarily the case. The MES explained if the resident had also been diagnosed with dementia, the dementia diagnosis would override the other diagnoses. The MES continued to explain the only thing which would necessitate a PASARR II referral for this type of dementia resident is a Legal Discharge for a psych change of Condition. The MES confirmed R81 did have a Legal Discharge due to a psych change of condition and a referral for a PASARR II should have been completed. The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities or related condition, a PASARR Level 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. A facility document titled Pre-admission Screening and Resident Review (PASARR) revised on 10/06/2022, revealed the need to refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon significant change in status. Also, the facility must notify the appropriate state mental health authority or state intellectual disability authority promptly after a significant change in the mental or physical condition of a resident who has a mental illness or intellectual disability for resident review.

Based on interviews, record review, and document review, the facility failed to ensure a care plan was revised after a resident elopement for 1 of 31 sampled residents (Resident 167). The deficient practice placed the resident at risk for inappropriate care, supervision, and accidents. Findings include: Resident 137 (R137) R137 was originally admitted to the facility on [DATE] with diagnoses including seizures, epilepsy, autistic disorder, schizophrenia, and anxiety disorder. A Nursing Progress Event Note dated 11/03/2024 at 7:10 PM, revealed the nurse was giving medications when R137 approached the nurse to call their mother around 8:00 PM. The note revealed the following information: At around 8:10 PM the CNA opened the front door remotely for a resident family member and the family member advised there was a resident outside wearing a red shirt. The CNA went outside to check and found R137 in the street in front of the building to the right. The CNA called for help and three CNAs brought R137 back to the building. At 9:15 PM the nurse called the physician to get an order for a Wonder Guard. At 9:15 PM the nurse went to the resident's room and the resident was not there. Staff looked for the resident again, and another nurse found R137 outside again. The nurse and a CNA brought R137 back inside at 9:40PM. At 11:30 PM, the CNA informed the nurse could not find R137. Staff looked outside and found R137 in front of the building at the right side near the bushes. R137 had refused to allow the staff to put the Wonder Guard on their leg and became aggressive toward staff. By 1:00 AM on 11/04/2024, R137 was asleep. According to the facility's investigation documentation, there is no evening. Staff buzz in visitors remotely in the evening due to no receptionist. When the door opens, the maglock does not close the door immediately, it stays open for at least a minute. It was thought the elopement occurred when the door was opened for a visitor or a food delivery person. A care plan for risk for elopement had documented R137 had an elopement. However, the care plan had not been revised with new interventions dated on or around 11/03/2024 documenting new preventative strategies to prevent future elopements. On 11/21/2024 at 7:59 AM, the Unit Manager (UM) acknowledged the care plan is the guide for how a person is taken care of in the facility and also acknowledged the current interventions had not worked in this event where R137 had eloped three times in four hours. The UM stated the care plan needs to be updated with new interventions to try to keep the resident safe in the facility. The UM acknowledged R137's care plan had not been revised with new interventions. On 11/21/2024 at 7:20 AM, the Director of Nursing (DON) revealed they would have expected new interventions to have been added to R137's care plan. A facility policy titled Comprehensive Care Plans and Revisions revised 03/02/2022 documented the facility should monitor the resident over time to help identify changes in the resident condition which may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery to include additional interventions on existing problems.

Based on interview and document review, the facility failed to ensure employee records contained evidence of current Nevada Automated Background System (NABS) clearance per Nevada Revised Statutes (NRS) 449.124, for 4 of 19 employee records reviewed (Employees 4, 5, 6 and 7). The deficient practice had the potential to allow unqualified employees to provide care for residents. Findings include: NABS Clearance regulatory language at NRS 449.123 documented the Administrator, or the person licensed to operate a facility, shall ensure information concerning the background and personal history of each employee, or contractor who worked at the facility was completed as soon as practicable and at least once every five years after the date of the initial investigation. NRS 449.124 documented each facility shall maintain records of the information concerning its employees which included, 1) a copy of the fingerprints submitted to the Central Repository for Nevada Records of Criminal History or proof of electronic fingerprint submission and a copy of the written authorizations provided by the employee, 2) proof the employees' fingerprints were submitted to the Central Repository, and 3) any other documentation of the information collected pursuant to NRS 449.123. On 11/21/2024, a review of 19 employee records conducted with the Staff Developer revealed the records of Employees 4, 5, 6 and 7 lacked evidence fingerprint-based background checks had been initiated and completed within five years from the prior screening date. -Employee 4 was hired as a Licensed Practical Nurse. The latest finger-print based background check with NABS clearance letter was completed on 09/20/2019. -Employee 5 was hired as a Certified Nursing Assistant (CNA). The latest finger-print based background check with NABS clearance letter was completed on 06/11/2019. -Employee 6 was hired as a CNA. The latest finger-print based background check with NABS clearance letter was completed on 10/17/2019. -Employee 7 was hired as a Maintenance Assistant. The latest finger-print based background check with NABS clearance letter was completed on 05/15/2019. On 11/21/2024 at 12:09 PM, the Staff Developer verbalized being responsible for ensuring each employee's screening was completed on hire and then every five years. The Staff Developer revealed fingerprints and clearance letter from NABS showing current eligibility for hire was to be documented in each employee record. The Staff Developer verbalized Employees 4, 5, 6 and 7 did not have a current (less than 5-year-old) NABS clearance letter. The Staff Developer indicated some employees had fingerprints done which had not been submitted to NABS as of yet. The Staff Developer indicated the fingerprinting process should have been initiated sooner so as to obtain NABS clearance for Employees 4, 5, 6, and 7 within the required time frame. The Staff Developer stated it was an oversight on the facility's part. On 11/21/2024, in the afternoon, the Administrator indicated a completed fingerprint-based background check with a NABS clearance letter confirming current eligibility was required for all employees. The Administrator verbalized the facility was expected to abide by state laws. The policy and procedure titled Licensure and Compliance with Federal, State, Local Laws, and Professional Standards, revised 04/17/2021, indicated the facility provided services in compliance with State laws, regulations, and codes. The policy and procedure titled Background Screening Policy: Associates, dated 08/20/2018, indicated background checks would be conducted to determine eligibility in accordance with relevant state laws.

Based on interview, record review, and document review, the facility failed to ensure the resident who had functional impairments was evaluated and appropriately discharged for 1 of 4 sampled residents (Resident 1). This failure could potentially lead to medical complications or adverse events which could result in hospitalization , prolonged illness, or even death. Findings included: Resident #1 (R1) Resident #1 (R1) was admitted on [DATE], with diagnoses including fracture of right pubis, urinary tract infection, protein-calorie malnutrition, abnormal posture, generalized weakness, and spondylolysis. R1 was admitted with a history of falling with injuries. R1 was alert and oriented and had a Brief Interview for Mental Status (BIMS) of 15/15 suggesting the patient was cognitively intact. An Occupational Therapy (OT) evaluation dated 10/16/2023, documented R1 had diagnoses of fracture of right pubis and generalized muscle weakness. The evaluation indicated R1 could perform toileting with maximum assistance, bathing with maximum assistance, lower body dressing with maximum assistance, and bed mobility with maximum assistance. A Physical Therapy (PT) evaluation dated 10/16/2023, documented R1 had diagnoses of fracture of right pubis and abnormal posture. The evaluation indicated R1 could perform bed mobility with maximum assistance. The evaluation also indicated R1 was dependent and could not perform transfers, ambulation, or wheelchair mobility in the patient's motorized wheelchair. A facility discharge summary dated 11/06/2023, documented R1 was contact guard assist with bed mobility, supervision to maximum assistance for activities of daily living (bathing and dressing), needed minimal assistance to complete transfers, and required maximum assistance for hygiene and toileting. The discharge summary indicated R1 was not continent of bowel and bladder, the skin was intact, no vision or hearing impairment, and no denture issues. The facility discharge summary documented the transfer or discharge was appropriate because R1's health had improved so the resident no longer required the services provided by the facility, and R1 was to be discharged to a group home with home health care OT, PT, and Nursing services ordered. The discharge summary indicated the discharge plan was discussed with the patient/family and the care team including case managers social services, and the therapy team. An Occupational Therapy (OT) discharge note dated 11/08/2023, documented R1 could perform toileting with maximum assistance, bathing with moderate assistance, and lower body dressing with supervision. A Physical Therapy (PT) discharge date d 11/07/2023, documented R1 could perform bed mobility with set up assistance, transfers with maximum assistance, and could maneuver the motorized wheelchair with supervision. The document also indicated R1 was dependent and could not perform ambulation or toilet transfers specifically. This document also recommended the resident required 24-hour caregiving. A Case Manager (CM) note dated 11/06/2023, documented the patient will discharge to group home with hospice at a specific address with the hospice marketer's name and phone number. The CM also documented the clinicals were sent via email to the home and hospice. On 10/08/2024 at 10:15 AM, the Case Manager (CM) revealed the CM did not know anything about the group home the resident was sent to besides what was written in the patient chart. The patient chart lacked documented evidence of completed discharge information. On 10/08/2024 at 10:30 AM, the Hospice Marketer revealed an interview with the hospice administrator was necessary to get the information needed. On 10/08/2024 at 10:36 AM, the Hospice Administrator revealed the facility where the patient was discharged to was not a group home. The facility the patient was discharged to, was an independent living home. The administrator revealed they provided hospice services to the patient inside this home. The administrator explained they provided a nurse 2 days a week and certified nursing assistants (CNAs) every day; but they do not provide 24-hour care. On 10/08/2024 at 11:00 AM, the Occupational Therapist (OT) revealed the OT believed the patient's discharge destination was a group home where the resident would be able to get some assistance. The OT explained the patient required one person to assist with transfers, especially the toilet because the resident could not stand and was only completing other transfers by scooting which could not be done, to the toilet. The OT stated the CM told therapy the resident was discharging to a group home. The OT stated if the resident was to be discharged to an independent living facility, the therapy goals would have been independent functional mobility, but this was never the goal because the resident was being discharged to a group home. The OT stated were not sure this was the safest or best place for the resident. On 10/08/2024 at 2:56 PM, the Social Services Director (SSD) revealed there is process in place for discharges. The SSD explained there is a discharge planning check-off document to make sure things are covered and do not get missed. The SSD indicated there is a group home sign off sheet the facility has for the group home to sign to show the group home did come in to evaluate the patient and can provide the care the resident needs. There is also an information sheet to be filled out to make the writing of the discharge easier. The SSD stated it is expected the person completing the discharge knows the resident so as to know what kind of care the resident will require, the therapy recommendations, and the family input if there is family. The SSD confirmed none of these forms/documents were found completed for this resident, nor was there any documented follow up for this resident after discharge. The SSD also stated the phrases group home and independent living home should not be used synonymously as they are not the same thing. The SSD also acknowledged the case management note was not clear enough and did not provide enough information for proper discharge documentation. The facility policy titled Transfers and Discharges dated 09/05/2024, documented the medical record should contain documentation or evidence of the patient's or resident representative's verbal or written notice of intent to leave the facility, a discharge care plan, and documented discussions with the resident, or if appropriate, the patient's representative, containing details of discharge planning and arrangements for post-discharge care. Complaint #NV00070132

Based on interviews, record review, and document review, the facility failed to ensure a care plan was revised after a resident-to-resident incident for 1 of 4 sampled residents (Resident 3). The deficient practice had the potential to place the resident at risk for inappropriate care, supervision, and accidents. Findings include: Resident 2 (R2) and Resident 3 (R3) R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, dementia with psychotic disturbances, dementia with anxiety, depression, and schizophrenia. R3 was admitted to the facility on [DATE] with diagnoses including hepatic encephalopathy, cognitive communication deficit, altered mental status, alcohol abuse, depression, and anxiety disorder. A Nursing Event Note dated 09/11/2024 at 12:56 PM, documented a communication note which revealed R3 walked into the dining room in the unit. When R3 approached the doorway, there was another resident, R2 passing through at the same time. Resident 3 put up their hand to stop R2 and swung at R2. At which time R2 kicked R3 and then R3 kicked R2. A staff member from activities intervened and separated the two residents. No injuries were observed, and no complaints were offered. The residents were unable to recall the incident when asked. Video footage of the incident was viewed on 10/08/2024 in the afternoon. The video revealed R3 blocked R2 in the doorway so R2 rolled over both feet of R3 in the wheelchair. Both exchanged words and were swinging their arms at each other followed by R3 kicking R2 in the abdomen and then R2 returned the kick, hitting R3 in the shin. According to the facility's investigation documentation, R2 had been refusing medications on and off for the past week and was sent to the hospital after the incident where R2 was kicked in the abdomen due to the residents change in condition. An updated care plan dated 09/17/2024 documented R2 had a resident-to-resident altercation, and the facility was going to assess R2 for the appropriateness of continuing to stay in the secured unit. The facilities census documents revealed the resident was sent out on 09/11/2024 and returned to the facility on [DATE] into a different unit. The medical record lacked documented evidence the care plans for R3 were revised to include preventative strategies for the most recent resident-to-resident altercation in the care plans. On 10/08/2024 at 1:27 PM, the Minimum (MDS) Licensed Practical Nurse (LPN) Coordinator revealed the nurses event note of these residents' altercation would be an after effect note. This would also have constituted a resident change of condition. After the altercation incident, there would have been an interdisciplinary team meeting to discuss the situation and check the residents' cares to make sure they are still appropriate and see what else can be done. The MDS Coordinator then explained would wait for the quarterly to update the care plan. On 10/08/2024 in the afternoon, the Assistant Director of Nursing (ADON) indicated the resident care plan could be updated by anyone after the incident or upon readmission like it was for R2. The ADON further explained if there was already a care plan for the situation, the facility won't necessarily update it any further after an event. When asked if the current interventions for R3 were working, the ADON said the interventions had not worked since there had been another altercation. The ADON explained it was important to update the care plan as it is what steers the care to be given and without an updated care plan, monitoring the care can be difficult. The ADON confirmed it would have been nice if both resident's care plans would have been updated, however, there was no point person to make sure the care plans are completed. A facility policy titled Comprehensive Care Plans and Revisions (revised 09/11/2024) documented the facility should monitor the resident over time to help identify changes in the resident condition which may warrant an update to the person-centered plan of care. When these changes occur, the facility should review and update the plan of care to reflect the changes to care delivery.

Based on observation, interview, record review, and document review the facility failed to ensure a resident with mitten restraints was assessed for the use of restraints and the physician order contained parameters for release of the restraint for 1 of 35 sampled residents (Resident 139). The deficient practice had the potential to cause physical and psychosocial harm to the resident. Findings include: Resident 139 (R139) was admitted on [DATE] with diagnoses including depression and bipolar disorder. A brief interview for mental status (BIMS) documented a score of 99 which indicated the resident was not able to complete the assessment. On 11/28/2023 in the morning R139 was lying in bed with mitten restraints on both hands. On 11/28/2023 in the afternoon R139 was lying in bed with mitten restraints on both hands. A physician order dated 11/29/2023 documented mitten to hand to protect finger from breakdown. The medication administration record indicated mitten restraint was being used initially on 10/10/2023. The medical record lacked documented evidence of an assessment prior to the use of a mitten restraint. The medical record lacked documented evidence of how the restraint was to be applied and used, and the time and frequency the restraint should be released. On 12/01/2023 at 12:55 PM, the Director of Nursing (DON) indicated the facility would occasionally use mitten restraints. The DON verbalized a physician order would be required with justification and restraint use and release procedures. According to the DON an assessment would be completed prior to use of restraint and a consent for the use of the restraint would be obtained. The facility policy titled Physical Restraints documented a consent form would be obtained prior to use of restraints, and a physician order was required for the use of the specific type of restraint. The order should include the specific type of restraint, the condition and medical symptom which warrants restraint use, where and how the restraint is to be applied and used, and the time and frequency the restraint should be released.

Based on interview and document the facility failed to refer a resident for a Pre-Admission Screening and Resident Review (PASRR) level II evaluation for 1 of 35 sampled residents (Resident 101). The deficient practice had the potential to deprive a resident of appropriate behavioral health services. Findings Include: Resident 101 (R101) was admitted on [DATE] with diagnoses including bipolar disorder, and pressure ulcer of the right plantar foot distal site. A review of the Nevada PASRR level I identification determination dated 06/30/2020 documented no mental illness, no intellectual disability, dementia, or related condition. The resident was appropriate for nursing facility placement. A review of the medical record revealed a diagnosis of bipolar disorder with an onset of 09/05/2022. A review of the medical record revealed a diagnosis of paranoid schizophrenia with an onset date of 11/15/2022. A Physician Order dated 11/16/2023 for Quetiapine Fumarate (Seroquel an antipsychotic) tablet 25 milligram (mg), give one tablet by mouth at bedtime for psychosis related to verbally aggressive behavior and resisting care. A Physician Order dated 09/07/2023 for Aripiprazole (Abilify an antipsychotic) tablet 5 mg, give one tablet by mouth one time a day for paranoid schizophrenia and resisting care. A Physician Order for Divalproex Sodium (Depakote an anticonvulsant) tablet delayed release 125 mg, give one tablet by mouth two times a day related to paranoid schizophrenia. The medical record lacked documented evidence a PASRR level II was completed for R101. On 11/30/23 at 1:34 PM, the Social Services Assistant indicated R101 should have been referred to the appropriate state agency for a PASRR level II evaluation due to the active psychiatric diagnoses. The Pre-admission Screening and Resident Review (PASRR) policy revised on 10/06/2022 documented any resident with newly evident or possible serious mental disorder, intellectual disability or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review.

Based on observation, interview, record review and document review, the facility failed to ensure person centered comprehensive care plans were developed for 3 of 35 sampled residents (Resident 330, 96 and 107), The deficient practice had a potential for staff not to provide a personalized care for residents. Findings include: 1) Resident 330 (R330) was admitted on [DATE], with diagnoses including chronic kidney disease, stage 3b and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. On 11/28/2023 at 2:53 PM, observed at R330's bedside was a medical device which had a suction type of device and a collection container. The device had tubing that was currently not connected to anything. R330 verbalized using an incontinent device called PureWick System. R330 indicated using the device for a while now and used it to control urinary incontinence and avoid urine contamination of the sacral wound. The History and Physical dated 11/20/2023, lacked documented evidence the primary physician was aware R330 was utilizing the PureWick device as part of urinary incontinence medical regimen. R330's comprehensive care plans revised 11/27/2023, documented Focus: Urinary Incontinence and At Risk for Skin Breakdown due to Incontinence revealed the interventions and tasks did not list the use of the PureWick urinary collection device. On 12/01/2023 at 9:40 AM, the director of staff development (DSD) indicated all medical equipment utilized in the facility would require the staff to receive training to ensure staff would be competent to handle the device and should be part of a resident's care plan. On 12/01/2023 at 10:51 AM, the DSD confirmed there was no care plan for the use of the PureWick device. 2) Resident 96 (R96) was admitted on ,d+[DATE] with diagnoses including chronic peripheral venous insufficiency and chronic systolic congestive heart failure (CHF). On 11/28/2023 at 10:16 AM, R96 was observed with +4 bilateral lower leg edema. R96 was noted to have bilateral lower wounds with a dressing. R96 was observed lying in bed with both lower extremities dangling on the side of the bed. On 11/29/2023 at 11:25 AM, R96 was observed lying in bed with no lower extremity elevation. R96 had a Physician Order for Furosemide 40 milligrams (water pill) give one tablet by mouth, two times a day for CHF and lower extremity edema. A Nursing Progress Note dated 10/20/2023 at 7:59 PM documented R96 continued to take medication as ordered. Resident continued with edema to bilateral feet, continued Lasix (water pill). A Nursing Progress Note dated 10/23/2023 at 7:24 PM, documented remained with edematous feet, already on Furosemide regimen; ace wrap intact; wound care in progress. Ambulating adlib in the hallway using a walker. No apparent distress noted. R96's comprehensive care plan lacked any focus problem on the lower leg edema and the interventions needed for its care. On 11/30/2023 at 2:46 PM, the unit manager confirmed R96's care plan did not have any focus problem addressing the resident's edema. The unit manager indicated it was nursing responsibility to ensure all care needs and focus problems be care planned. 3) Resident 107 (R107) was initially admitted on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and chronic obstructive pulmonary disease, unspecified. On 11/28/2023 at 3:21 PM, observed R107 lying in bed with both fingers curled towards the palm and bilateral wrists pulling towards the body. There were no hand rolls applied to the residents' hands and no support was provided to keep the wrist properly aligned. A Rehabilitation Services Multidisciplinary Screening Tool dated 10/02/2023, documented Occupational Therapy: Patient continued with baseline activities of daily living (ADL) function. Total assistance with ADLs. No skilled OT indicated at this time. On 11/01/2023 at 7:20 PM, a Skilled Note documented noted contractures. Resident was dependent on staff for all activities of daily living. R107's comprehensive care plan lacked documented evidence for a focus on contractures and interventions in preventing the progression of contractures. On 11/30/2023 at 2:30 PM, the Unit Manager confirmed Resident 107 had been developing bilateral hand contractures. The Manager confirmed there was no order for hand rolls to prevent the progress of contractures of the hands. The Manager confirmed there was no care plan for hand contractures of any contractures that could occur for a limited mobility resident. The facility policy titled Comprehensive Care Plans and Revisions, issued on 03/02/2022; Reviewed on 08/22/2023, documented the facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team. The care is to reflect the care delivery, this can include interventions on existing problems.

Based on observation, interview, record review, and document review, the facility failed to ensure a shower or bed bath was provided at least twice a week for 1 of 35 sampled residents (Resident 26). The deficient practice had the potential to pose the risk of compromised hygiene and potential adverse effects on the resident's skin or skin breakdown. Findings include: Resident 26 (R26) was admitted on [DATE], with diagnoses including quadriplegia (paralysis affecting all limbs and the body from the neck down) and contracture. The Minimum Data Set - Brief Interview of Mental Status dated 09/07/2023, documented a score of 15/15, which indicated R26's cognitive status was intact. The Minimum Data Set functional status dated 09/07/2023, documented R26's personal hygiene required extensive assistance and total dependence with bathing. The Activity Daily Living (ADL) - bathing record dated 09/18/2021, documented R26 preferred Monday and Thursday day shift showers. The Admission/Readmission Collection Tool dated 09/19/2021, documented R26 required total assistance with personal hygiene and bathing. R26 had gait disturbance, unsteadiness, and balance issues due to quadriplegia, putting R26 at risk for pressure ulcers. A Care Plan revised on 10/14/2019, documented R26 was totally dependent on one to two staff members for ADL care due to quadriplegia. The interventions included providing showers twice weekly, with bed baths in between. The Shower List in 100 Hall documented R26's shower days as Mondays and Thursdays. On 11/28/2023 at 12:50 PM, R26 was verbally alert and oriented, lying in bed in a supine position. R26 indicated the facility did not have enough Certified Nursing Assistants (CNAs), leading to the scheduled shower not being provided. R26 indicated the designated shower days were Monday and Thursday and was totally dependent on staff with showers. R26 indicated the lack of a shower and bed bath had made R26 uncomfortable. The Point of Care Response History for November 2023, documented R26's shower or bed bath was inconsistently provided on the following occasions: Week 1: no shower/one bed bath Week 2: one shower and one bed bath Week 3: one shower Week 4: one shower The ADL flow sheet for R26's shower/bath for October and November lacked documented evidence that a shower or bed bath was consistently provided twice weekly with bed baths in between, as indicated in the care plan. On 12/01/2023 at 8:38 AM, the Director of Nursing (DON) indicated each resident was entitled to receive a shower twice weekly. The DON confirmed there was a lack of documented evidence R26's shower or bed bath was provided as scheduled. On 12/01/2023 at 1:54 PM, the Unit Manager (UM) confirmed R26's medical records lacked documented evidence a shower or bed bath was consistently provided at least twice a week. The UM indicated R26's shower was scheduled on Mondays and Thursdays. The UM explained if the resident refused, the nurse should have been informed so the resident could have been encouraged, and if refusal persisted for three times, the physician should have been informed, and refusal should have been care planned. On 12/01/2023 at 2:24 PM, a Certified Nursing Assistant (CNA) indicated a resident's shower was scheduled twice weekly. The CNA explained the shower schedule was indicated in the nursing assignment to assigned CNA. On 12/01/2023 at 2:27 PM, a CNA indicated each resident should have been given a shower or bed bath twice a week and documented under the point of care. The CNA explained If a resident refused, the nurse should have been informed, and the shower sheet signed by the CNA and a nurse should have been submitted. The CNA indicated R26 was bedbound and totally dependent on showers, requiring extensive assistance. A facility policy titled Activities of Daily Living dated 08/23/2023, documented a resident unable to carry out ADL should receive the necessary services to maintain grooming, personal, and oral hygiene.

Based on observation, interview, record review and document review the facility failed to 1) implement interventions for edema for 1 of 35 sampled residents (Resident 96); 2) ensure a resident received follow-up oncology services for a lesion on the left arm as recommended for 1 of 35 residents (Resident 103). The deficient practice had the potential to affect a resident's overall health, treatment, and care. Findings include: 1) Resident 96 (R96) was admitted on ,d+[DATE] with diagnoses including chronic peripheral venous insufficiency and chronic systolic congestive heart failure (CHF). On 11/28/2023 at 10:16 AM, R96 was observed with +4 bilateral lower leg edema. R96 was noted to have bilateral lower extremity wounds with a dressing. R96 was observed lying in bed with both lower extremities dangling on the side of the bed. On 11/29/2023 at 11:25 AM, R96 was observed lying in bed with no lower extremity elevation. R96's Physician's Order dated 08/21/2023, documented Furosemide tablet 40 milligrams (water pill) give one tablet by mouth, two times a day for CHF and lower extremity edema. A Nursing Progress Note dated 10/20/2023 at 7:59 PM, documented R96 continued to take medication as ordered. Resident continued with edema to bilateral feet, continued Lasix (water pill). A Nursing Progress Note dated 10/23/2023 at 7:24 PM, documented remained with edematous feet, already on Furosemide regimen; ace wrap intact; wound care in progress. Ambulating adlib in the hallway using a walker. No apparent distress noted. The medical lacked documented evidence that any nonpharmacological interventions were provided to the resident after identifying the edema to both lower extremities. On 11/30/2023 at 2:46 PM, the Unit Manager confirmed R96 had lower extremity edema due to the poor circulation of both legs. The Unit Manager confirmed there were no orders for nonpharmacological interventions to address R96's lower extremity edema. The Unit Manager indicated a physician order to elevate the resident's lower legs was obtained. On 12/01/2023 at 2:46 PM, the Director of Nursing (DON) indicated the facility did not have a policy specific for the care and monitoring of edema. The DON verbalized nonpharmacological care of a resident with edema was considered to be basic nursing standards of practice. 47860 2) Resident 103 (R103) was admitted on [DATE] with diagnosis including muscle weakness and malignant neoplasm of colon. A Brief Interview for Mental Status (BIMS) documented a score of 15 which indicated the resident was cognitively intact. A Progress Note dated 09/26/2023, documented pathology reported a diagnoses of left elbow lesion identified as a squamous cell carcinoma lesion and R103 to follow up with an outpatient dermatology. On 11/28/2023 at 10:39 AM, R103 explained a biopsy was conducted on a left elbow lesion and identified as cancerous, but there was no follow up appointment completed. R103's left elbow lesion was observed as an approximate dime sized dried scaled over lump. On 12/01/2023 at 8:52 AM, a Unit Manager indicated R103's left elbow lesion was determined to be cancerous, and a wound doctor was treating the lesion. The Unit Manager reported R103 had an appointment scheduled at an office to include oncology and dermatology on 10/27/2023, but that appointment was canceled. On 12/01/2023 at 9:32 AM, a Treatment Nurse confirmed a biopsy was conducted on the left elbow lesion, which was confirmed to be a squamous cell carcinoma lesion. The Treatment Nurse explained the current intervention was for R103 to follow up with a dermatologist and oncologist. The Treatment Nurse indicated the Unit Manager would schedule appointments for residents. On 12/01/2023 at 2:16 PM, the Director of Nursing (DON) explained there was no documentation the resident saw an oncologist from October 2023 to current. On 12/01/2023 at 5:25 PM, the Maintenance Director indicated overseeing the transportation staff who may assist in scheduling appointments for residents. The Maintenance Director explained R103 was transported to an appointment to an oncology/dermatology office on 10/27/2023, however upon arrival, the office was closed. The Maintenance Director considered that appointment as canceled for R103 and transportation staff would not have scheduled a follow up appointment until a request form was received by nursing staff, which was not received. A facility policy titled Transportation Coordination and Service, last reviewed on 07/17/2023, documented the facility would assist the resident in making necessary appointments for services not provided in the facility.

Based on observation, interview, record review and document review, the facility failed to ensure resident was assessed and interventions were put into place for hand contractures for 1 of 35 sampled residents (Resident 107). The deficient practice failed to implement interventions needed to avoid progression of a resident's contractures. Findings include: Resident 107 (R107) R107 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and chronic obstructive pulmonary disease, unspecified. On 11/28/2023 at 3:21 PM, observed R107 lying in bed with both hands curled towards the palm and bilateral wrists pulling towards the body. There were no hand rolls applied to the residents' hands and no support was provided to keep the wrist properly aligned. On 11/30/2023 at 10:08 AM, the Director of Rehabilitation indicated R107 was recently screened upon re-admission from the hospital. Any resident needing further occupational therapy, restorative or assistive devices would be assessed during the screening and implemented. A Rehabilitation Services Multidisciplinary Screening Tool dated 10/02/2023, documented Occupational Therapy: Patient continues with baseline activities of daily living (ADL) function. Total assistance with ADLs. No skilled OT indicated at this time. On 11/01/2023 at 7:20 PM, a Skilled Note documented contractures. Resident was dependent on staff for all activities of daily living. R107's Physician's Order lacked documented evidence for current orders for hand splint or management of hand contractures. On 11/30/2023 at 2:30 PM, the Unit Manager confirmed Resident 107 had been developing bilateral hand contractures. The Unit Manager confirmed there was no order for hand rolls to prevent the progress of contractures of the hands. The Unit Manager confirmed there was no care plan for hand contractures. The Unit Manager indicated the most recent rehabilitation screen should have identified the issue and initiated interventions. The facility policy titled Alignment and Pressure-reducing Device Application, Long-term Care Revised: February 20, 2023, documented various assistive devices are available to help maintain correct body positioning and prevent complications that commonly occur when a resident must be on prolonged bed rest. Alignment and pressure-reducing devices (or pressure-redistribution devices) include the heel suspension device, heel suspension foam cushion, abduction pillow, trochanter roll, hand roll, and wheelchair cushions.

Based on observation, interview, record review and document review, the facility failed to ensure staff had training and a physician's order for a urinary collection device utilized within the facility for 1 of 35 sampled residents (Resident 330), The deficient practice had a potential for staff not to be aware and properly care for a resident with a specialized medical device. Findings include: Resident 330 (R330) was admitted on [DATE], with diagnoses including chronic kidney disease, stage 3b and encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. On 11/28/2023 at 2:53 PM, observed at R330's bedside was a medical device which had a suction type of device and a collection container. The device had tubing that was currently not connected to anything. R330 verbalized using an incontinent device called PureWick System. R330 indicated some staff were not aware of how to use the device and had to instruct them in how to apply the device. R330 had been using the device for a while now to control urinary incontinence and avoid urine contamination of the sacral wound. The History and Physical dated 11/20/2023, lacked documented evidence the primary physician was aware R330 was utilizing the PureWick device as part of urinary incontinence medical regimen. R330's medical record lacked a physician order to utilize the PureWick device. On 12/01/2023 at 9:40 AM, the Director of Staff Development (DSD) indicated all medical equipment utilized in the facility would require the staff to receive training to ensure staff would be competent to handle the device. On 12/01/2023 at 10:24 AM, a Unit Manager and two Licensed Practical Nurses confirmed not getting any type of training for the PureWick urinary collection device. On 12/01/2023 at 10:51 AM, the DSD confirmed there was no physician's order in place and the facility lacked documented evidence of training provided to the staff for the proper implementation of the urinary collection device. The facility policy titled Continence Care, Genitourinary, and Gastrointestinal last reviewed on 08/24/2023, documented if assessment reveals that resident is clinically appropriate, the facility should obtain an order from a licensed independent practitioner, prior to the use of the PureWick system. Implementation of Device: The facility should follow the Lippincott procedure for the application, maintenance, and removal of the External Urine Collection Device Use, Female.

Based on record review, interview and document review, the facility failed to ensure acceptable parameters of nutritional status were maintained and a Dietitian recommendations for medication regimen review were followed to address a severe weight gain for 1 of 26 sampled residents (Resident #25). Findings include: The American Diabetes Association 2016 Standards of Medical Care in Diabetes established [MEDICAL CONDITION] in hospitalized patients had been defined as blood glucose greater than 140 milligram/deciliter (mg/dL). The Standards indicated for overweight and obese patients with type 2 diabetes, a sustained reduction of 5% of the initial body weight, reduced the need for medications to control blood glucose. The United States Department of Health and Human Services National Institutes of Health Practical Guide for the Identification, Evaluation and treatment of [REDACTED]. - Underweight: BMI less than 18.5 kg/m2 - Normal weight: BMI 18.5 - 24.9 kg/m2 - Overweight: BMI 25 - 29.9 kg/m2 - Obesity class 1: BMI 30 - 34.9 kg/m2 - Obesity class 2: BMI 35 - 39.9 kg/m2 - Extreme Obesity class 3: BMI more than 40 kg/ m2 Facility policy entitled Weight Monitoring, revised 3/1/2013, ,documented: - For evaluating weight changes: -Weight variances are reviewed for residents with a 5% weight change in 30 days, 7.5% weight change in 90 days and 10% weight change in 180 days. This includes gain or loss. - Any resident who experiences an unplanned weight loss, significant weight change, or undesirable weight change is assessed and monitored by the interdisciplinary team. - Unplanned weight gain in a resident may have significant health implications and therefore is addressed . Note: Appropriate goals are noted on the care plan. Each identified resident with weight change has a current nutrition assessment/ progress note. - The Interdisciplinary Care Plan team addresses the root cause of the weight loss/poor intake or weight gain, assess dining needs if indicated, provides realistic and measurable goals, indicates specific and individualized interventions, and more as needed. The resident's interdisciplinary care plan reflects the current interventions, evaluations, and revisions . The facility Weight Monitoring policy described the severity of the weight changes as follows: - Significant weight loss/gain: 5 % in one month, 7.5 % in three months and 10 % in six months. - Severe weight loss/gain: greater than 5 % in one month greater than 7.5 % in three months and greater than 10 % in six months. Resident #25 Resident #25 was originally admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #25' s clinical record revealed Physician orders [REDACTED]. - Accuchecks (CBG capillary blood glucose, the level of circulating blood glucose as measured by glucometer analysis of a fingerstick sample) before meals and at bed time with regular insulin sliding scale for diabetes - Insulin [MEDICATION NAME] 35 units subcutaneous injection at bed time for diabetes - [MEDICATION NAME] 500 milligram (mg) twice a day for diabetes - [MEDICATION NAME] 1 mg by mouth twice a day for [MEDICAL CONDITION]. - [MEDICATION NAME] 500 mg by mouth twice a day for mood disorder. - [MEDICATION NAME] 400 mg three times a day for neuralgia. Resident #25's Physician orders [REDACTED]. In addition, the insulin [MEDICATION NAME] dose was increased as follow: - 4/14/15: 38 units at bed time. - 4/15/15: 41 units at bed time. - 7/9/15: 45 units at bed time. - 7/30/15: 5 units in the morning and 45 units at bed time. - 10/18/15: 30 units in the morning and 45 units at bed time. Care Plan for [MEDICAL CONDITION] (high blood sugar) /[DIAGNOSES REDACTED] (low blood sugar) dated 2/2/15, documented goals to minimize [MEDICAL CONDITION]/[DIAGNOSES REDACTED] episodes that included nutritional interventions. Care Plan for Nutrition dated 2/2/15, documented the resident was at nutrition risk as evidenced by Ideal Body Weight (IBW) more than 130 %, Body Mass Index (BMI) more than 27, [DIAGNOSES REDACTED]. The Nursing Care plan dated 2/2/15, directed staff to monitor the resident for evidence of side effects of the medication [MEDICATION NAME] that included increase of appetite, somnolence, sedation, dizziness, tremor, ataxia, [MEDICAL CONDITION], agitation and hypertension. Nursing Care Plan for the anti-psychotic medication, [MEDICATION NAME], dated 2/2/15, directed staff to monitor the resident for evidence of side effects of the medication that included sedation, drowsiness, dry mouth, constipation, blurred vision and weight gain. Medication book used by the facility as a reference titled Nursing 2016 Drug Handbook, documented the following adverse reactions for [MEDICATION NAME] and [MEDICATION NAME]: - [MEDICATION NAME]: increased appetite. - [MEDICATION NAME]: weight gain and [MEDICAL CONDITION] Medication Administration Records (MAR) from February to December 2015, revealed several doses of regular insulin had been administered due to the high levels of blood glucose in addition to the insulin [MEDICATION NAME]. Psychiatrist Progress Notes dated 6/19/15, 8/6/15, 8/13/15, 8/27/15, 9/3/15, 9/17/15, 9/24/15, 10/8/15 and 12/28/15, documented there was no evidence of side effects of the medications such as diarrhea, dry mouth, constipation, [MEDICAL CONDITION], hypersomnia, nausea, breathing problems, vomiting, aggression, depression or anxiety. The Progress Notes documented the appetite was fair (decreased), weight was stable and continued with the same medications and doses. On 2/5/15, a Nutrition Data Collection/Assessment documented the resident was admitted with a BMI of 29.3, weight 147 pounds (lbs), height 59 inches and Ideal body weight (IBW) 98 lbs. The Registered Dietitian (RD) recommended an A 1 C laboratory test (a blood test that provides information about average levels of blood glucose used for diabetes management) due to the resident's [DIAGNOSES REDACTED]. On 4/2/15, a Pharmacy Consultation Report documented a review of the medication [MEDICATION NAME] was performed and laboratory test was recommended for monitoring liver toxicity of the medication. The report did not address the increase of the appetite with potential for weight gain as a medication side effect. In addition, the report documented a recommendation for monitoring A 1 C on the next convenient lab day and then every three months if therapeutic goals were not being met. The clinical record lacked documented evidence the Attending Physician was notified about the Pharmacist and the RD's recommendation for A 1 C laboratory test. The Laboratory results history evidenced the A 1 C test was performed on 1/19/16 per the Endocrinologist request and the result was 8.9 % (reference range: 4.4 % - 5.6 %). On 4/7/15 at 1:27 PM, Resident at Risk (RAR) Progress Note Review made by a Licensed Practical Nurse (LPN) documented the resident's current weight was 158 lbs. The resident had a weight gain of 3.7 % in 35 days and 15 lbs. gained in 49 days. The note indicated weight issue was discussed with the resident and small portions offered but the resident refused. On 5/7/15, RAR Progress Note Review made by a LPN documented the resident's current weight was 168 lbs, the resident gained 8 lbs. in 7 days and 21 lbs. in 91 days. Physician's diet order was a consistent carbohydrate (CCHO) diet with large portions. The MAR indicated [REDACTED] 6:30 AM: 236 mg/dL 11:30 AM: 292 mg/dL 4:30 PM: 300 mg/dL 9:00 PM: 346 mg/dL The note indicated current plan of care would continue. The RAR review lacked documented evidence the Attending Physician was notified about the severe weight gain and the CBG levels. On 5/12/15, Quarterly Nutrition Documentation made by the Dietary Manager revealed the resident had a weight increase of 15.17 % in 91 days and a BMI of 33.3. the MAR indicated [REDACTED] 6:30 AM: 320 mg/dL. 11:30 AM: 350 mg/dL. 4:30 PM: 344 mg/dL. 9:00 PM: 398 mg/dL. The document did not identify a significant weight change in the Weight Review section. The document was not signed by the RD and lacked evidence the high blood glucose was assessed as part of the nutritional evaluations. On 5/12/15, the Minimum Data Set (MDS) Quarterly Assessment, documented zero (0) weight gain in Section K Swallowing/Nutritional Status. On 5/20/15, the RD wrote a Nutritional Progress Note indicating the resident had 15.86 % weight gain in 90 days and 6.33 % weight gain in 30 days. The Dietitian recommended snacks between meals, salad with lunch and dinner, cereal with breakfast, regular diet regular sized portions. The RD recommended a medication review, since the resident was receiving [MEDICATION NAME]. There was no evidence the Attending Physician or the Attending Psychiatrist were notified about the RD recommendation for medication review due to the weight gain and increased appetite. Physician's Progress Notes dated 4/27/15 to 12/8/15, did not acknowledge the resident's ongoing weight gain. On 6/3/15, RAR documented the resident's current weight was 172 lbs. with a BMI of 34.3 and 11.69 % weight gain in 91 days. The MAR indicated [REDACTED] 6:30 AM: 300 mg/dL 11:30 AM: 124 mg/dL 4:30 PM: 314 mg/dL 9:00 PM: 333 mg/dL The report indicated the RD educated the resident about unplanned weight gain. The current plan of care would continue. The RAR review lacked documented evidence high blood glucose was assessed as part of the nutritional evaluations. There was no evidence the Attending Physician was notified about the severe weight gain and the CBG levels. On 6/6/15, a Pharmacy Consultation Report documented a review of the medication [MEDICATION NAME] was performed and a recommendation for a dose reduction was given. The report did not identify the severe weight gain and [MEDICAL CONDITION] as a side effect of the medication. On 7/8/15, a Nutritional Progress Note documented the resident's current weight was 176 lbs. with a weight gain over 10 % in 90 days and 180 % of the IBW. The report indicated the resident was receiving medications that contained weight gain as a side effect including [MEDICATION NAME] and [MEDICATION NAME]. The RD repeated the recommendation for a medication review due to weight gain. On 7/9/15, a RAR Progress Note Review documented the resident had a weight gain of 16 lbs. in 91 days. The MAR indicated [REDACTED] 6:30 AM: 228 mg/dL 11:30 AM: 355 mg/dL 4:30 PM: 374 mg/dL 9:00 PM: 271 mg/dL The RD repeated the recommendation for a medication review due to weight gain. The note indicated current plan of care would continue. The RAR review lacked documented evidence high blood glucose was assessed as part of the nutritional evaluations. There was no evidence the Attending Physician was notified about the severe weight gain and the CBG levels. On 8/10/15, a Physician SOAP ( Subjective, Objective, Assessment and Plan) Note documented the resident was morbidly obese with a current weight of 181 lbs. The note did not identified the weight gain as a severe weight change. On 8/12/15, a Quarterly Nutrition Documentation identified significant weight change of 7.78 % in 91 days and 27.59 % in 180 days. On 8/24/15, a Nutritional Progress Noted documented the resident had a weight gain over 10 % in 91 days and 180 % of the IBW. The RD indicated in the notes that from a nutritional perspective the weight gain was excessive and unreasonable and a recommendation for medication review was given for [MEDICAL CONDITION] and [MEDICAL CONDITION] medications. There was no evidence the Attending Physician or the Attending Psychiatrist were notified about the RD recommendation for medication review due to the weight gain. On 10/3/15, a RAR Progress Note Review documented the resident had a weight gain of 10 lbs. in 28 days and 22 lbs. in 91 days with an average of 66 % meals intake. The note indicated current plan of care would continue. The RAR review lacked documented evidence high blood glucose was assessed as part of the nutritional evaluations. There was no evidence the Attending Physician was notified about the severe weight gain. On 10/8/15, a RAR Progress Note Review documented the resident's current weight was 196 lbs. and the Attending Physician was aware about the significant weight change. The note indicated current plan of care would continue. The RAR review lacked documented evidence high blood glucose was assessed as part of the nutritional evaluations. On 10/29/15, a RAR Progress Note Review documented the resident's current weight was 203 lbs. , 207 % of the IBW, weight gain 3.57 % in 7 days and 26.88 % in 180 days. The note indicated the resident was receiving regular diet regular texture with small tossed salad with lunch and dinner, intake average of 97 %. [MEDICAL CONDITION] laboratory test result was 1.04 uIU/ml (international units over a milliliter), within normal limits (Reference range 0.34-5.60 uIU/ml) On 11/5/15, a RAR Progress Note Review documented the resident's current weight was 205 lbs. , 205 % of the IBW, weight gain 11.05 % in 91 days and 19.54 % in 182 days, receiving regular diet regular texture with small green salad with lunch and dinner, intake average of 90 %. The note indicated the RD would review the resident. On 11/12/15, the Quarterly Nutrition Documentation revealed the resident's current weight was 203 lbs. with 12.78 % weight gain in 91 days and 21.56 % in 182 days. On 12/31/15, a RAR Progress Note Review documented the resident's current weight was 210 lbs. The note indicated current plan of care would continue. The RAR review lacked documented evidence high blood glucose was assessed as part of the nutritional evaluations. Review of the physician's orders [REDACTED]. In addition, [MEDICATION NAME] 500 mg twice a day was ordered on [DATE] and increased to 850 mg twice a day. Weight History documented the following weights: 2/2/15: 147 lbs. (initial weight on admission) 3/2/15: 154 lbs., 4.76 % weight gain in 30 days. 5/4/15: 168 lbs., 14.28 % weight gain in 90 days representing a severe weight gain. 8/3/15: 181 lbs., 22.44 % weight gain in 180 days representing a severe weight gain. 9/7/15: 194 lbs. 10/5/15: 196 lbs. 11/9/15: 203 lbs. 12/7/15: 207 lbs. 12/28/15: 210 lbs. The Weight History revealed the resident gained 63 lbs. from 2/2/15 to 12/28/15. Resident #25's laboratory analysis documented the following fasting glucose (a test that measures blood glucose levels after a period of fasting, usually at least eight hours without food or liquid) results: - 10/9/15: 147 mg/dL (reference range 70-99 mg/dL) - 1/6/16: 207 mg/dL - 119/15: 277 mg/dL On 1/29/16 at 8:43 AM, a Pharmacist explained medication regimen review included review of doses, laboratory results, drug interaction and side effects in a monthly basis. In addition, the Pharmacist performed medication reviews per facility request. The Pharmacist and a Pharmacy Manager indicated the Pharmacy records did not document specific request to medication review due to weight gain as a side effect of a medication and no recommendations were given for this matter. The Pharmacy Manager verbalized there was no request for medication review from the Dietitian. On 1/29/16, a Physician Assistant (PA) indicated the weight gain issue was discussed couple times with Nurses and with the resident. According to the PA, the collection of the weight data was not accurate and diet and exercise were issues that contributed to the weight gain, this was a concern discussed with the RD. The PA verbalized a recommendation for Psychiatric consult for medication review was given. The PA indicated a consult with an Endocrinologist was requested due to weight gain and uncontrolled blood sugar. The PA did not provide the dates when the discussion with the RD was performed and when the recommendations for Psychiatrist and Endocrinologist consult were requested. The PA acknowledged no physician progress notes [REDACTED]. On 1/5/16, a Consultation/Referral form documented the resident was seen by a Endocrinologist on 1/5/16. On 1/29/16 at 11:20 AM, the former RD that provided care to the resident explained discussions were conducted several times with the resident about the weight gain. The RD indicated a communication was sent to the Attending Physician recommending the medication review due to the weight gain. New interventions were implemented such as changing the diet to CCHO, reducing portions and providing salad with lunch and dinner. The RD verbalized the resident's appetite increased and a medication review was necessary since the resident was receiving at least three medications that could cause the weight increase. The RD believed it was a medication induced weight gain. On 1/29/15 at 11:57 AM, the current RD explained communication with pharmacy had not occurred. If a resident had significant weight, an assessment would be performed. The RD explained if from the nutritional perspective there were no reasons for weight changes, a medication review and increase of activities would be recommended. On 1/29/15 at 2:10 PM, the resident verbalized she wanted to lose weight. The resident verbalized she would feel better if she could lose some pounds. The resident acknowledged having spoken with the Physician and the RD regarding the weight gain. The resident confirmed she was receiving food and snacks from a friend. The clinical record for Resident #25 revealed that nutritional assessments were not performed by a Licensed/Registered Dietitian from 8/25/15 to 12/31/15, the resident's consumption of food from outside sources was not evaluated, repeated recommendations for review of medication orders were communicated to the physician and pharmacist, recommendations for laboratory testing for A1C levels were followed by the physician, physician progress notes [REDACTED]. The clinical record lacked evidence that recommendations from other Health Care Practitioners, such as the RD and Pharmacist were reviewed and addressed by the attending physician and the psychiatrist. The clinical record lacked evidence the Interdiscliplenary Team evaluated the resident's care plan to ensure the recommendations from the RD and Pharmacist were implemented, that nationally recognized standards of practice for Type II Diabetes Mellitus and facility policy and procedures were followed.

Based on observation, interview and document review, the facility failed to identify and implement interventions to maintain hot water temperatures in safe ranges which created a potential for harm throughout the facility including resident rooms, resident care areas and public bathrooms. Findings include: On 2/26/14 at 11:02 AM, the hot water temperature in the bathroom in Resident Room 405 was 125.9 degrees Fahrenheit. The Director of Maintenance was informed the water had to be within the range of 95-110 degrees Fahrenheit. The Director of Maintenance said, "There's nothing I can do about it." The Director of Maintenance indicated this issue was isolated to the 400 Hall, and indicated if the temperature was adjusted, residents would complain of cold showers. At 11:30 AM, in the 400-Hall boiler room, the Director of Maintenance read the temperature gauge on the equipment, and indicated it was 120 degrees Fahrenheit. In the morning of 2/27/14 a review of maintenance documents was conducted. One three-ring binder contained only one page with only one entry. The Director of Maintenance indicated that it was the temperature log book, and it had only one entry because the facility had just started logging temperatures. On 2/26/14 at 11:33 AM, the water temperature in Room 300 was documented at 118 degrees Fahrenheit. On 2/26/14 at 11:35 AM, the water temperature in Room 305 was documented at 122 degrees Fahrenheit. On 2/26/14 at 11:40 AM, the water temperature in Room 310 was documented at 130 degrees Fahrenheit. On 2/26/14 at 11:43 AM, the water temperature in the shower room on the 300 Hall was documented at 120 degrees Fahrenheit. On 02/26/14 at 11:26 AM, the hot water temperature in room 104 was 130 degrees Fahrenheit. On 02/26/14 at 11:28 AM, the hot water temperature in room 122 was 126 degrees Fahrenheit. On 02/26/14 at 11:32 AM, the hot water temperature in room 124 was 128 degrees Fahrenheit. On 2/26/14, a calibrated thermometer was used between 11:40 AM and 11:50 AM to record the following water temperatures in the secured unit and in the beauty shop: - Resident Room 116 was 125.5 F - Resident Room 117 was 125.3 F - Resident Room 114 was 136.4 F - Resident Room 111 was 132.5 F - The beauty shop was 121.1 F On 2/26/14 at 11:49 AM, a Licensed Practical Nurse (LPN) confirmed the observation of the water temperature in Resident Room 111 was 132.5 F. The LPN verbalized the water temperature was not safe. On 2/26/14, a calibrated digital thermometer was used between 11:30 AM and 11:40 AM to record the following water temperatures in the 300 Hall and front lobby public restroom: - Resident room 316 was 124 F - Resident room 320 was 123.8 F - Resident room 321 was 124.5 F - Resident Bathing/Shower room was 136.6 F - Front Lobby Public Restroom was 125 F On 2/26/14, a calibrated thermometer was used between 11:35 AM and 12:10 PM to record the following water temperatures in the 200 Hall: - Resident room 204 was 130.0 F - Resident room 221 was 132.0 F On 2/26/14, between 11:35 AM and 11:41 AM, the following water temperatures were obtained on 400 Hall: - Resident Room 405 was 120 F - Resident Room 415 was 120 F - Shower Room was 121 F On 2/26/14 at 12:05 PM, after the water temperature was assessed by the inspectors, an immediate jeopardy situation was identified for issues regarding unsafe water temperatures in the residents' rooms, residents' care areas and a public restroom. The immediate jeopardy was abated on 2/26/14 at 1:12 PM.

Based on record review, interview and document review, the facility failed to ensure acceptable parameters of nutritional status were maintained to avoid severe weight gain for 1 of 42 residents (Resident #11) and follow physician orders [REDACTED].#15). Findings include: Resident #11 Resident #11 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #11's clinical record documented a physician order [REDACTED]. Resident #11's Behavioral Interdisciplinary Care Plan dated 6/11/13 and 6/17/13, and the Behavior/Intervention Monthly Flow Record for August, September, October, November, and December 2013, directed the staff to monitor side effects for the anti-psychotic medication [MEDICATION NAME] as one of the approaches for the medication management. The care plan documented a list of side effects of [MEDICATION NAME] that should be monitored, which included weight gain. Resident #11's Weight History log documented the following weights: - 6/11/13: 123 pounds (lbs) - 6/18/13: 125 lbs - 6/24/13: 126 lbs - 7/2/13: 128 lbs - 7/8/13: 129 lbs - 8/5/13: 141 lbs - 8/12/13: 140 lbs - 8/19/13: 142 lbs - 8/26/13: 140 lbs - 9/3/13: 143 lbs - 9/9/13: 145 lbs - 9/16/13: 148 lbs - 9/23/13: 147 lbs - 9/30/13: 150 lbs - 10/7/13: 151 lbs - 10/14/13: 152 lbs - 10/21/13: 150 lbs - 10/28/13: 151 lbs - 11/4/13: 164 lbs - 11/11/13: 164 lbs - 11/18/13: 165 lbs - 11/25/13: 167 lbs - 12/2/13: 169 lbs - 12/ 9/13: 171 lbs - 12/16/13: 174 lbs - 12/23/13: 176 lbs - 12/30/13: 173 lbs - 1/6/14: 175 lbs - 1/13/14: 177 lbs - 1/20/14: 178 lbs - 1/27/14: 180 lbs - 2/3/14: 183 lbs - 2/11/14: 185 lbs The weight history revealed Resident #11 gained 64 lb in 8 months. The physician's diet order dated 6/10/13, for Resident #11 was a regular diet with regular texture. Resident #11's Behavior/Intervention Monthly Flow Record for August, September, October, November, and December 2013, did not identify weight gain as a side effect for the use of [MEDICATION NAME] medication. Resident #11's dietary progress notes dated 8/12/13, and signed by the Dietary Technician (DT), documented the resident's weight was 141 lbs and the percentage of weight gain was 9.3% in 28 days. The notes documented: "Patient education to be done to discuss risk & (and) benefits of continued wt (weight) gain". There was no documented evidence other interventions were implemented or recommended for the weight gain. Nutritional Progress Notes dated 8/21/13, and signed by a Licensed Dietitian (LD), documented Resident #11 weight gain was 10.94% in the last 48 days. The progress note indicated the LD recommended to continue current diet plan and monitoring as needed. Resident #11's dietary progress notes dated 9/9/13, and signed by the DT, documented the resident's weight was 143 lbs, a 14.4% of weight gain in 77 days. The progress note documented a recommendation was made to discontinue the fortified juice. Resident #11's dietary progress notes dated 9/20/13, and signed by the DT, documented the resident's weight was 148 lbs, a 18.4% of weight gain in 90 days. The document indicated the resident did not desire to gain weight. The progress note documented a recommendation was done for small portion meals per resident request. There was no documented evidence the recommendation was made after an evaluation by an LD. Resident #11's clinical record documented a physician order [REDACTED]. Nutritional Progress Notes dated 11/6/13, and signed by an LD, documented Resident #11 weight gain was 15.4% in the last 77 days. The progress note indicated the LD recommended to continue current diet plan and monitoring as needed. There was no new recommendation to address Resident #11's weight gain. Dietary progress notes dated 11/13/13 and signed by the DT, revealed Resident #11's weight was 164 lbs and triggered for 8.6 % of weight gain in 7 days and 31.2 % in 139 days. The progress note documented: "Will continue current plan wt (weight) has remained stable x (times) 7 days". Dietary progress notes dated 12/6/13 and signed by the DT, documented Resident #11 continued gaining weight. The progress note revealed a recommendation was done for nursing to review the resident's medications that could cause weight gain. There was no documented evidence the recommendation was made after an evaluation by an LD. Resident #11's clinical record revealed a Nursing note date 12/6/13, that documented the physician was notified the resident gained 44 lbs in 167 days. The note indicated the physician ordered a psychiatric consult to review [MEDICATION NAME] due to the continuous weight gain. The clinical record lacked documented evidence a psychiatric evaluation was performed to review [MEDICATION NAME] medication. Physician's Progress Notes dated 12/15/13, documented Resident #11 had gained 44 lb since admission and a dietary consult was required. There was no documented evidence a physician order [REDACTED]. Physician's Progress Notes dated 12/18/13, documented Resident #11 had gained 62 lbs in 8 months and a dietary consult was required to decrease calorie intake. There was no documented evidence a physician order [REDACTED]. There was no documented evidence a dietary consult was performed. Dietary progress notes dated 1/7/14, and signed by the DT, revealed Resident #11's weight was 175 lbs, a 15.13% of weight gain in 84 days and 35.66% in 182 days. The progress note indicated the resident continued on a regular diet and small portions and received medications that could impact the weight. There were no new interventions or approaches to address the continuous weight gain. Dietary progress notes dated 2/5/14 and signed by the DT, revealed Resident #11's weight was 183 lbs. The progress note indicated the resident remained on a regular diet with small portions and receiving medications that could facilitate the weight gain. The progress note documented recommendations had been made for medication review. There was no documented evidence the recommendation was made after an LD evaluation. The record lacked documented evidence the medications were reviewed since the significant weight gain was identified on 8/12/13. Resident #11's Medication Regimen Review was checked for "no new irregularities (NI)" on 7/2/13, 8/7/13, 9/9/13, 10/2/13, 11/11/13, 12/3/13, 1/8/14 and 2/4/14. Resident #11's clinical record lacked documented evidence the medications were reviewed after the significant weight gain was identified on 8/12/13. Resident #11's Nursing Notes dated 2/21/14, documented an Interdisciplinary team (IDT) meeting was held with the resident's power of attorney (POA) to discuss Resident #11's continuous weight gain. The Nursing Notes indicated the resident's physician was called for the review of [MEDICATION NAME] and a new order was obtained to reduce [MEDICATION NAME] dose from 250 mg to 125 mg in the morning and [MEDICATION NAME] from 500 mg to 250 mg at bed time. Resident #11's initial Minimal Data Set (MDS), section K dated 6/17/13, documented the resident's weight was 123 lbs. The MDS quarterly assessment dated [DATE], documented the resident weight was 148 lbs, more than 5% weight gain in one month. The MDS quarterly assessment dated [DATE], documented the resident's weight was 174 lbs, more than 5% weight gain in six months. Resident #11's MDS lacked documented evidence a change of condition assessment was performed for the resident's severe weight gain. The Nutrition Care Plan dated 6/10/13, lacked documented evidence the care plan was updated after the significant weight gain was identified on 8/12/13. The care plan did not document approaches to address weight gain issues. On 2/27/14 at 3:44 PM, an LD explained Resident #11's weight gain was monitored and recommendations were given to the nursing staff. The LD verbalized the resident's weight gain issue was not related to the diet since the resident was receiving small portions meals and the fortified juice was discontinued. The LD indicated the weight gain could be related to a medication and recommendations for the medication review were given to the nursing staff. The LD acknowledged Resident #11's Nutrition Care Plan lacked appropriate interventions and approaches to address the resident's undesirable weight gain. On 2/28/14 at 10:40 AM, the Director of Nursing (DON) explained restorative nurse aids (RNA) were responsible to weigh and document resident's weight. The DON stated if a weight variance was detected, RNA documented in resident's record and report to the Charge Nurse. The DON indicated if a significant weight variance was identified, the IDT followed the case closely and reported to the physician. The DON explained the IDT made recommendations to dietary, pharmacy and physician to address the problem. The DON verbalized all recommendations made by IDT should be validated by the physician. The DON acknowledged the IDT did not address the issue when the severe weight gain was identified in Resident #11 on 8/12/13. The DON confirmed Resident #11's Nutrition Care Plan was not updated and lacked interventions and approaches to address the weight gain issue. On 3/4/14 at 1:38 PM, a Pharmacist Consultant explained several factors including drug interactions, residents weight, and side effects were considered during the medication regimen review. The Pharmacist confirmed [MEDICATION NAME] was a drug that could cause increased body weight. Resident #11's Nutrition Data Collection/ assessment dated [DATE], indicated the resident's Body Mass Index (BMI) was 21.3 kg/ m2 (kilograms per square meter). Nutritional Progress Notes dated 11/13/13 and signed by an LD, documented Resident #11's BMI was 29 kg/ m2. The progress note indicated the LD recommended to continue current diet plan and monitoring as needed. Resident #11's Dietary Note dated 2/5/14, revealed the BMI was 31.9 kg/ m2. The United States Department of Health and Human Services National Institutes of Health Practical Guide for the Identification, Evaluation and treatment of [REDACTED]. - Underweight: BMI less than 18.5 kg/m2 - Normal weight: BMI 18.5 - 24.9 kg/m2 - Overweight: BMI 25 - 29.9 kg/m2 - Obesity class 1: BMI 30 - 34.9 kg/m2 - Obesity class 2: BMI 35 - 39.9 kg/m2 - Extreme Obesity class 3: BMI more than 40 kg/ m2 Facility policy entitled Weight Monitoring, revised 7/23/09, read: "- For evaluating weight changes: -Weight variances are reviewed for residents with a 5% weight change in 30 days, 7.5% weight change in 90 days and 10% weight change in 180 days. This includes gain or loss. - Any resident who experiences an unplanned weight loss, significant weight change, or undesirable weight change is assessed and monitored by the interdisciplinary team. - Unplanned weight gain in a resident may have significant health implications and therefore is addressed... - The Interdisciplinary Care Plan team addresses the root cause of the weight loss/poor intake or weight gain, assess dining needs if indicated, provides realistic and measurable goals, indicates specific and individualized interventions, and more as needed. the resident's interdisciplinary care plan reflects the current interventions, evaluations, and revisions..." The facility Weight Monitoring policy described the severity of the weight changes as follow: - Significant weight loss/gain: 5 % in one month, 7.5 % in three months and 10 % in six months. - Severe weight loss/gain: greater than 5 % in one monthgreater than 7.5 % in three months and greater than 10 % in six months.

Based on observation, interview and clinical record review, the facility failed to ensure 3 of 3 sampled residents (Resident #1, #2 and #3) were provided fall prevention measures in accordance with the facility's policy. Findings include: The facility's policy entitled, Standing Strong Together, Falling Stars/Falling Leaf Program (undated) documented a fall risk assessment was completed on admission, following a serious injury, with a significant change MDS (Minimum Data Set), quarterly and as necessary. If a resident scored a 10 or above, the resident was assessed for participation in the Falling Stars/Falling Leaf Program and or Hip Protection Program. The care plan updated to reflect current fall risk status and resident specific interventions designed to reduce occurrence. If a resident had a fall the resident was assessed by the interdisciplinary team to determine if the resident would benefit from participating in the Falling Staff/Falling Leaf program. The care plan was to be reviewed and updated as needed to reflect the current fall risk and resident specific interventions designed to reduce occurrence. The residents identified to participate in the falling Star/Falling Leaf program were recognized by a star or leaf on the resident's door and on the resident's chart. Resident #2 Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The Initial Data Collection Tool/Nursing Service form dated 3/23/12, documented Resident #2 was alert, able to communicate her needs and had adequate vision. The section entitled Physical Functioning: Bed Mobility documented the resident required assistance to reposition herself and was unable or unwilling to recognize the need to wait for assistance before getting out of bed. The section on the form for Falls and Safety documented Resident #2 had a fall within the last 6 months. The physician's orders for Resident #2 were reviewed. There was no physician's order for a tab alarm, low bed or other fall risk interventions. The Fall Risk assessment dated [DATE], documented Resident #2's fall risk was 18. The documentation on bottom of the form indicated a resident who scored a 10 or higher was at risk. The back of the Fall risk Assessment form documented if a resident scored a 10 or above, the fall risk interventions should be initiated. Document interventions below and on the resident's care plan. The form lacked documentation fall prevention interventions had been initiated. Nurse's notes dated 5/6/12 at 11:45 PM, Resident #2 was found on the floor on her left side by the air conditioning unit. The resident was awake, alert, orientated times 3. Resident #2 stated she was watching television and fell asleep while seated on the bed. The resident fell on the floor hitting her left hip and forehead on the floor sustaining a bump. Instructed to lay on bed next time she feels drowsy and to call staff for assistance. The Fall Risk assessment dated [DATE], documented Resident #2's fall risk was 19. The back of the Fall risk assessment documented encourage the use of call light for needs and offer a tab alarm. The medical record lacked documentation the tab alarm had been offered, explained to the resident or refused by the resident. The quarterly Fall Risk assessment dated [DATE], documented Resident #2's fall risk was 19. The back of the Fall risk assessment form lacked documentation fall prevention interventions had been initiated. Nurse's Notes dated 7/1/12 at 6:00 AM, documented Resident #2 was found sitting on the bed, alert, oriented times 3 and verbally responsive. The resident was not able to grasp with her left hand as she stated her wrist hurt. The resident indicated she had gotten out of bed to use the restroom, when coming out of the restroom she missed the door handle and fell backwards out side of the restroom. The resident stated she tried to stop or lessen the fall buy using her left hand and that was why her wrist hurts. The nurse's notes documented Resident #2 stated she did not call for help because she thought she could make it by herself. Safety precautions were reviewed with the resident and instructed to call for help as needed to prevent serious injury form falls. Nurse's notes dated 7/1/12 at 12:20 PM, documented x-ray completed of resident's left wrist. At 1:00 PM, documented the result of the left wrist x-ray was received. Impression acute impacted [MEDICAL CONDITION] wrist. At 1:50 PM, a physician's order was received to transfer the resident to the hospital emergency room for further evaluation and treatment. The Fall Risk assessment dated [DATE], documented Resident #2's fall risk was 20. The back of the Fall Risk Assessment documented send to the hospital, x-ray and resident education. The form lacked documentation as to what resident education had been given or what other fall prevention measures were implemented. The care plan dated 3/23/12, documented Resident #2 was at risk for injury from falls due to history of falls, limited mobility, status [REDACTED]. The care plan documented found on floor stated "I fell ", left wrist fracture. The approaches listed on the care plan included place call light, water and personal items within reach, 1/2 side rails times 2 as enabler, assist with all transfers and ambulation, resident had been educated and re-educated regarding the use of the call light and calling for help during transfers. On 7/5/12 at 1:40 PM, Resident #2 was in her room sitting in a chair with a sling on her left arm. The resident did not have a fall risk bracelet on or a star outside her door on the name plate. The resident verbalized she had fallen asleep sitting on the edge of her bed in June of 2012 and hit her head. Resident #2 stated she had recently fallen and fractured her wrist. The resident indicated she had awoken and had to use the bathroom. The resident indicated she missed the bathroom door handle and fell . The resident stated she had used her left arm to stop the fall. Resident #2 stated she had not used her walker or called for help from the staff. Resident #2 stated the staff had not spoken to her about the use of a tab alarm. On 7/10/12 at 9:30 AM, a Licensed Nurse (LN) and Unit Manager stated the residents on the Falling Star Program were to have a star on the name plate outside the door, an orange arm band/bracelet on. LN and Unit Manager stated if a Fall Risk Assessment documented a score of 10 or above and/or a history of falls the resident would be placed on the Falling Star Program. The LN stated if the Fall Risk Assessment was 10 or above a tab alarm should be initiated right away and then assess the resident for other needs. The LN verbalized a physician's order was required for a tab alarm. On 7/10/12 at 10:30 AM, the Director of Nursing (DON) stated if the resident had been offered and/or refused the tab alarm it should be documented in the medical record. The DON confirmed there was no documentation the tab alarm had been offered or the resident had refused the tab alarm. On 7/10/12 at 11:00 AM, Employee # 3, a Unit Manager, verbalized stated she was responsible to make sure the Falling Star Program was followed a star on outside the resident's door, fall risk bracelet and the tab alarm in place. The Unit Manager stated after a fall the resident need to be assessed by the Registered Nurse (RN) and the floor nurse would update/ revise the care plan. The Unit manager stated the facility's fall committee meet every week on Wednesday. The fall committee discussed all falls, made sure the Falling Star Program and the tab alarms were in place. On 7/10/12 at 11:00 AM, the DON stated with a Fall Risk Assessment score of 18, the resident should have been on the Falling Star Program. The resident should have had a fall risk bracelet applied, a star on the name plate outside the door and a tab alarm in place. The DON confirmed these measures were not done and the facility's policy was not followed. The DON confirmed there was no documentation the Falling Star Program was implemented, no documentation of fall interventions such as a tab alarm were implemented. The DON confirmed there was no fall risk interventions implemented after the quarterly fall risk assessment was done on 6/19/12. Resident #3 Resident #3 was admitted to re-admitted on [DATE], discharged [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE], documented Resident #3 had a score of 20. On the back of the Fall Risk Assessment for there were no documented interventions. The Initial Data Collection Tool/Nursing Service form dated 5/23/12, documented Resident #3 was alert with short term memory loss, adequate vision and able to communicate her needs. The section of the form entitled Physical Functioning: Bed Mobility indicated Resident #3 required assistance to reposition her self and the use of the bed rails. The assessment form indicated Resident #3 had no history of falls. The resident was admitted to the facility with the [DIAGNOSES REDACTED]. A discharge summary dated 6/19/12, indicated Resident #3 had been a long-term resident of the facility. On 5/19/12, the resident complained of knee pain. An x-ray noted the resident had a fracture. The resident told the facility she had fallen earlier in the morning when she was trying to get herself out of bed for breakfast. The admission orders [REDACTED]. The admission orders [REDACTED]. On 7/10/12 at 8:30 AM, Resident #3 was in bed alert with eyes open, oxygen on per nasal cannula and 1/2 side rails up times 2. There was no star on the resident's name plate outside her room, no fall risk band/bracelet or tab alarm in place. Resident #3 stated she had fallen in May 2012, while trying to get to the bathroom in he morning and hurt her knee. The resident stated before she fell she was able to stand to transfer. The resident verbalized since the fall she was not able to transfer and required the lift. On 7/10/12 at 11:15 AM, a Certified Nursing Assistant (CNA) stated she was assigned to care for Resident #3. The CNA verbalized the resident was not a fall risk, but that the resident had fallen in the past. The CNA stated the Falling Star program was for resident's who were a fall risk. The residents have a star outside their door, bracelet to alert others the resident was a fall risk. The bed in low position and an alarm on. Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Initial Data Collection Tool/Nursing Services dated 5/9/12, documented Resident #1 had no history of falls, but judgement may place resident as risk for injury. A Fall Risk assessment dated [DATE], documented Resident #1 had a fall risk score of 22. The documentation on the form indicated, a resident who scores 10 or higher is at risk. The form lacked documentation as to what interventions had been put into place for Resident #1. The interim Care Plan dated 5/9/12, documented Resident #1 was at risk for physical injury from falls. The documented interventions included: low bed and assist with transfers. The area to indicate the number of persons to assist with transfers was blank or not filled in. Nurse's Notes dated 5/29/12 at 7:20 AM, documented the Licensed Nurse (LN) was called by a CNA to Resident #1's room. The resident was found sitting on the floor. The resident was able to move all extremities with out any problem. The family and MD notified. On 5/29/12 at 10:00 AM, a physician's order was received may use tab alarm in bed. High risk for fall. On 7/5/12 at 11:30 AM, the DON stated the Fall Risk Assessment form dated 5/9/12, should have contained documented interventions for a fall risk score of 22. The DON stated there was no fall risk interventions in place before the 5/29/12 fall. The DON stated there should have been at least a bed alarm in place. During the interview on 7/5/12, the DON verbalized a physician's order was required for a High/Low bed or a low bed. The DON confirmed there was no physician's order for the High/Low bed or a Low bed. On 7/5/12 at 1:15 PM, a CNA stated before her fall Resident #1 was a little confused and was a one person assist with transfers The resident was able to turn side to side with a little assistance.