Every finding on record at Life Care Center of South las Vegas

Based on interview, record review and document review, the facility failed to ensure 1) blood glucose (BG) levels were obtained on admission, 2) discharge summary recommendations for diabetes management were discussed or clarified with the attending physician, and orders for BG monitoring and Insulin sliding scale were obtained for a resident with type one diabetes mellitus, 3) BG levels were obtained during a change of condition, and 4) the facility had a clear diabetes management process or protocol for 1 of 40 sampled residents (Resident 161). The deficient practice potentially resulted in diabetic-related complication requiring hospitalization.Findings include:Resident 161 (R161) was admitted on [DATE], with diagnoses including type one diabetes mellitus, and encounter for surgical amputation of right toe due to gangrene.1) On [DATE] at 3:35 PM, a Registered Nurse (RN) recalled admitting R161 on the evening of [DATE]. The RN explained when residents with diabetes were admitted , a baseline blood glucose would be obtained. According to the RN, this value would be communicated to the physician and would guide the physician on whether to place the resident on a low sliding scale or the regular sliding scale unless the resident was not Insulin-dependent. The RN indicated the resident's baseline blood glucose value would also guide the physician on the frequency of BG monitoring orders for the resident. The RN acknowledged a BG check was not obtained when R161 was admitted due to an oversight on the part of the RN.On [DATE] at 10:38 AM, the medical records director confirmed there was no record a BG was obtained when R161 was admitted on [DATE] in the evening. The first BG check for the R161 was recorded on [DATE] at 9:10 AM with a result of 209 milligrams (mg) per deciliter (dl) (Reference range: 70 mg/dl to 99 mg/dl when fasting or under 140 mg/dl two hours after a meal).2) A review of the hospital Discharge summary dated [DATE], revealed R161 underwent amputation of the right third toe on [DATE]. R161 was receiving Insulin Glargine (long-acting) twice a day (BID) and Insulin Humalog (fast-acting) before meals (AC) and at bedtime (HS) following a sliding scale. R161's BG was monitored twice a day with the Insulin Glargine administration and before meals and at hour of sleep for the Insulin Humalog administration.The hospital discharge medication reconciliation dated [DATE], included Insulin Glargine (Lantus injection) 100 units/milliliter (ml) vial, 50 units subcutaneously daily. A free text med rec notes read please consider sliding scale insulin while at rehab facility. Please also consider splitting long-acting Insulin to twice daily.The medical record lacked documented evidence discharge recommendations to put R161 on an Insulin sliding scale and splitting the long-acting Insulin twice daily were communicated to the physician.The medical record lacked documented evidence the admitting nurse clarified, obtained and transcribed orders for BG checks for R161 and the frequency thereof. On [DATE] at 3:35 PM, the RN who admitted R161 on the evening of [DATE] explained the facility did not have an admissions nurse but all nurses were trained in the admission process. The RN indicated hospital discharge summaries were thoroughly reviewed for all newly admitted residents and discharge medications typically were transcribed as admission orders and may be changed by the physician on the next physician visit. The RN indicated it was possible the RN focused on R161's discharge medications and missed the free text rec notes in the hospital discharge summary. The RN acknowledged not reaching out to the physician on the evening of [DATE] to obtain clarification orders regarding the resident's Insulin orders and frequency of BG checks.On [DATE] at 11:14 AM, Licensed Practical Nurse (LPN1) explained the admitting nurse would enter admission orders based on the hospital discharge summary for newly admitted residents and the unit managers would review and confirmed the medication orders. LPN1 indicated BG checks were typically done with Insulin administration while diabetics who were not receiving Insulin had BG checks twice daily, once per shift.On [DATE] at 11:17 AM, LPN2 indicated nurses would follow hospital discharge medications which may or may not include Insulin for newly admitted residents with a diagnosis of diabetes. LPN2 would discuss and seek clarification with the physician with regards to diabetes medication orders and frequency of BG checks. LPN2 indicated even if a diabetic resident was not on Insulin, they would obtain orders to perform BG checks at least twice daily.On [DATE] at 11:23 AM Unit Manager 1 (UM1) explained admission orders were reconciled with the physician who typically followed hospital discharge medication orders. Diabetic residents who were not receiving Insulin should have BG checks at least twice daily while diabetic residents on Insulin would be checked per physician recommendations.On [DATE] at 11:37 AM, UM2 explained hospital discharge medications were entered and followed as admission orders and the physician decided whether to place diabetic residents on a low or regular sliding scale. If the frequency of BG checks were not specified, then BG monitoring would occur at least twice a day.On [DATE] at 12:19 PM, the Director of Nursing (DON) explained nurses would enter orders based on the hospital discharge summary and unit managers would review and confirm the orders the following day except for weekends. The DON indicated R161 only had a long-acting Insulin in the hospital discharge summary to be given at night, and the BG monitoring was embedded with this order.On [DATE] at 11:51 AM, R161's attending physician indicated expecting the admitting nurses to communicate hospital recommendations for an Insulin sliding scale with the physician. The physician indicated they would have absolutely agreed to follow hospital recommendations for an Insulin sliding scale and to divide the resident's long-acting Insulin into two administrations. The physician verbalized being under the impression the facility protocol was to perform BG checks at least three times a day for residents being admitted with a diagnosis of diabetes.The medical record revealed R161 who was admitted on 11/2025 at 9:30 PM and discharged to the hospital on [DATE] at 6:02 AM, had four BG checks taken, as follows:- On [DATE] at 9:10 AM, 209 mg/dl- On [DATE] at 8:49 AM,147 mg/dl- On [DATE] (no time available) 147 mg/dl- On [DATE] at 11:00 AM, 220 mg/dlOn [DATE] at 11:54 AM, the Clinical Quality Coordinator reviewed R161's medical record and confirmed the last BG check was on [DATE] at 11:00 AM (220 mg /dl) and there was no BG obtained when the change of condition was identified on [DATE] at 5:32 AM. The Clinical Quality Coordinator indicated many things could have led to the DKA namely; infection, multiple co-morbidities, amputation surgery and the resident could have eaten something to cause the hyperglycemia and DKA. 3) A nursing admission/readmission collection tool dated [DATE], revealed R161 was admitted with a diagnosis of type one diabetes mellitus, was alert and oriented to person and place, able to make needs known, exhibited no behaviors, and was able to sign consents.An alert note dated [DATE] (4:37 AM), documented R161 was trying to get out of bed all night and was constantly redirected back to bed to prevent fall.A health status note dated [DATE] (5:32 AM), documented R161 was being sent out to the hospital due to a change in condition. Specifically, R161's heart rate was 32 beats per minute, hands were cold, Oxygen saturation was 82 % (normal 95% to 100%) on room air, deep rapid respirations, unable to speak due to catching breath and was lethargic. Physician called.An event note dated [DATE] at 6:02 AM, documented R161 sent to hospital by emergency services.The medical record lacked documented evidence a blood glucose level was obtained when vital signs were taken during R161's change of condition.On [DATE] in the afternoon, the Regional Director of Clinical Services and Clinical Quality Coordinator were present when the Director of Nursing (DON) stated a BG check was not done during R161's change of condition because it was not yet time.On [DATE], in the morning, the Regional Director of Clinical Services and Clinical Quality Coordinator stated a BG check should have been obtained when R161 had a change of condition, specifically altered mental status and abnormal vitals signs on [DATE] because the resident was a known diabetic.The facility's Changes in Resident's Condition or Status policy reviewed [DATE], documented a change of condition included a significant change in the resident's physical, mental, or psychosocial status, a deterioration of health or a life-threatening condition or clinical complications. The facility would utilize the Lippincott procedure.The Lippincott procedure: Change in status, identifying and communicating, long-term care, revised [DATE], documented the nurse would identify and address any changes from baseline in the resident's status early to avoid complications. Chronic diseases may lead to potentially life-threatening conditions so the nurse must keep up to date on monitoring for changes. The Table List for chronic conditions included monitoring for hypoglycemia or hyperglycemia for residents with diabetes.4) On [DATE] at 1:00 PM, the Regional Director of Clinical Services confirmed the facility did not have a diabetes management protocol but went by physician's orders.A history of present illness dated [DATE], revealed R161 arrived at the hospital by emergency medical services (EMS), the resident was confused and had altered mental status. R161's blood glucose level was greater than 600 mg/dl at 9:08 AM and was recorded at 807 mg/dl at 9:13 AM. R161 had severe confusion found to be in diabetic ketoacidosis (DKA - a life-threatening medical emergency which occurs when the body lacks Insulin to convert blood sugar into energy. Without Insulin, the body starts breaking down fat, producing acids called ketones making the blood dangerously acidic) requiring intensive care unit (ICU) level admission.An independent history provided by emergency medical services (EMS) dated [DATE], revealed R161 came from a skilled nursing facility and had been confused since 2:00 AM, R161 was typically oriented x 2 to 3 but zero for EMS.A hospital Discharge summary dated [DATE], revealed R161 was admitted to the hospital on [DATE] with acute encephalopathy likely metabolic in the setting of DKA and stress hyperglycemia. R161 was started on an Insulin drip, placed on a DKA protocol and moved to the ICU for further assessment and management. R161 was intubated due to altered mentation and respiratory failure. Palliative care was discussed and R161 was discharged to hospice care on [DATE].A report received by the State Agency on [DATE], revealed R161 expired on [DATE] under hospice care.The facility's Admissions policy revised [DATE], documented the facility would provide uniform guidelines for admission or residents to the facility. Prior to admission, the resident would be evaluated for physical, emotional and social needs through a pre-admission screening process. The referral will contain medical findings, diagnoses, treatment to follow, prescribed diet, medication and treatment orders, short- and long-term goals and signed orders for immediate care. This should be available at the time of admission. A physician must personally approve in writing a recommendation that an individual be admitted to the facility, each resident must remain under the care of a physician, who would provide orders for the resident's immediate care and needs.Complaint 2992873

Based on interview, record review and document review, the facility failed to ensure the attending physician conducted an independent, thorough review of a hospital discharge summary for a resident admitted with Type one diabetes mellitus for 1 of 40 sampled residents (Resident 161). The deficient practice resulted in the resident experiencing diabetic-related complications which required rehospitalization. Findings include:Resident 161 (R161) was admitted on [DATE], with diagnoses including type one diabetes mellitus, and encounter for surgical amputation of right toe due to gangrene.The hospital Discharge summary dated [DATE], revealed R161 underwent amputation of the right third toe on [DATE]. R161 was receiving Insulin Glargine (long-acting) twice a day (BID) and Insulin Humalog (fast-acting) before meals (AC) and at bedtime (HS) following a sliding scale. R161's BG was monitored twice a day with the Insulin Glargine administration and before meals and at hour of sleep for the Insulin Humalog administration.The hospital discharge medication reconciliation dated [DATE], included Insulin Glargine (Lantus injection) 100 units/milliliter (ml) vial, 50 units subcutaneously daily. A free text med rec notes read please consider sliding scale insulin while at rehab facility. Please also consider splitting long-acting Insulin to twice daily.The medical record lacked documented evidence discharge recommendations to put R161 on an Insulin sliding scale and splitting the long-acting Insulin twice daily were reviewed and addressed by the attending physician.On [DATE] at 11:51 AM, R161's attending physician indicated expecting the admitting nurses to communicate hospital recommendations for an Insulin sliding scale. The physician indicated they would have agreed to follow hospital recommendations for an Insulin sliding scale and to divide the resident's long-acting Insulin into two administrations. The physician verbalized being under the impression the facility protocol was to perform BG checks at least three times a day for residents being admitted with a diagnosis of diabetes.A health status note dated [DATE] (5:32 AM), documented R161 was being sent out to the hospital due to a change in condition. Specifically, R161's heart rate was 32 beats per minute, hands were cold, Oxygen saturation was 82 % (normal 95% to 100%) on room air, deep rapid respirations, unable to speak due to catching breath and was lethargic. Physician called.A hospital Discharge summary dated [DATE], revealed R161 was admitted to the hospital on [DATE] with acute encephalopathy likely metabolic in the setting of DKA and stress hyperglycemia. R161 was started on an Insulin drip, placed on a DKA protocol and moved to the ICU for further assessment and management. R161 was intubated due to altered mentation and respiratory failure. Palliative care was discussed and R161 was discharged to hospice care on [DATE].A report received by the State Agency on [DATE], revealed R161 expired on [DATE] under hospice care.On [DATE] in the morning, the Regional Director of Clinical Services and the Clinical Quality Coordinator indicated physicians had an obligation to conduct a thorough independent review of the hospital discharge summary to include discharge medications, treatment services received at the hospital and free text recommendations and not merely rely on nurses.The facility's Physician Services policy reviewed [DATE], revealed each resident was supervised by a licensed physician to provide quality medical care, routine scheduled physician visits, monitor resident care and make changes as needed. Physician services include but are not limited to resident evaluation - physicians complete, sign and date comprehensive assessment history and physician within 72 hours within 24 hours prior to all admissions to the facility.Complaint 2992873

Based on observation, interview, record review and document review, the facility failed to ensure resident rooms and bathrooms were in good repair for 9 of 72 resident rooms. The deficient practice had the potential to negatively impact on the residents' quality of life.Findings include:On 05/20/2026 in the afternoon, an observation tour of the facility with a life safety code (LSC) inspector revealed the following: -room [ROOM NUMBER] had a broken doorknob with handle easily removed.- room [ROOM NUMBER] had a loose toilet that moved from left to right, and the toilet base was not sealed and secured to floor. - room [ROOM NUMBER] had damage to flooring underneath toilet with missing tiles. The toilet paper holder was missing from wall exposing a sharp edge.- room [ROOM NUMBER] had scraped drywall with paint coming off at the head of bed releasing scraps and powder-like substance accumulating on floor.- room [ROOM NUMBER] had a broken bathroom door, and a broken ceiling tile which had the potential to fall on the resident, as it was directly above the toilet area. - room [ROOM NUMBER] had a loose toilet.- room [ROOM NUMBER] had a loose toilet.- room [ROOM NUMBER] had a loose toilet.- room [ROOM NUMBER] had a loose toilet. On 05/20/2026 at 1:30 PM, the Executive Director indicated being informed of the LSC survey findings with the physical environment. The Administrator verbalized expecting the entire team (clinical and non-clinical) to complete a work order for all broken or damaged areas in the facility to enable maintenance staff to fix the issues in a timely manner. The Administrator stated every resident was entitled to a safe, homelike environment.The facility's Home Like Environment policy reviewed 04/01/2026, documented the facility would provide a safe, clean, comfortable and homelike environment for each resident. The facility's Keeping a Resident's Room in Order policy reviewed 04/02/2026, documented it is the responsibility of all staff to create a homelike environment and promptly address any cleaning needs to keep rooms orderly. Housekeeping and maintenance services would be provided to maintain sanitary, orderly and comfortable interior.

Based on observation, interview, record review and document review, the facility failed to ensure care and management of a resident's intravenous line (IV) were included in the resident's baseline care plan for 1 of 40 sampled residents (Resident 171). The deficient practice placed the resident at risk for infection.Findings include:Resident 171 (R171) was admitted on [DATE], with diagnoses including traumatic subdural hemorrhage and unspecified dementia.On 05/18/2026 at 10:38 AM, R171 laid supine in bed and appeared to be nonverbal. A midline with single lumen and purple port was observed on R171's left upper arm with dressing dated 05/08/2026. There was no IV pole or pump observed in the room.The medical record lacked documented evidence a baseline care plan was developed for R171's IV line.On 05/20/2026 at 12:15 PM, the Director of Nursing (DON) indicated R171's IV line should have been included in the resident's care plan, but this was not done.The facility's Baseline Care Plan policy dated 08/28/2017, documented the facility must develop and implement a baseline care plan for each resident which includes instructions needed to provide effective and person-centered care of the resident. The care plan would be developed within 48 hours of admission and contain minimum healthcare information necessary to properly care for the residents.

Based on observation, interview, record review and document review, the facility failed to ensure physician orders were followed for an indwelling catheter for 1 of 40 sampled residents (Resident 2). The deficient practice placed the resident at risk for a urinary tract infection (UTI).Findings include:Resident 2 (R2) was admitted on [DATE], with diagnoses including paraplegia, obstructive uropathy and urine retention.On 05/18/2026 in the morning, R2 was rolled to right side while the wound care nurse provided treatment to a sacral wound. A covered urinary bag was observed hanging on the right side of the bed.A physician order dated 04/07/2026, documented indwelling catheter to straight drainage. Size: 18 French Bulb: 10 cubic centimeters. Change for infection, obstruction or when the closed system was compromised as needed for stage four sacral wound.A physician order dated 04/07/2026, documented to perform catheter care every shift.On 05/21/2026 at 9:35 AM, the Unit Manager explained R2 was a paraplegic with an infected sacral pressure ulcer requiring use of a Foley catheter. The Unit Manager reviewed R2's medical record and indicated there was no documentation the Foley catheter had been replaced since admission. The Unit Manager entered R2's room and indicated needing to obtain information from the resident.On 05/21/2026 at 11:54 AM, the Unit Manager indicated R2 had a 16 French Foley catheter with orange port. R2 informed the Unit Manager the catheter was exchanged last week per resident's request and R2 themselves requested staff to use a 16 French Foley catheter.The medical record lacked documented evidence of the resident's request for a Foley catheter exchange using a 16 French Foley was recorded and a physician order was obtained for insertion of a 16 French catheter.The medical record lacked documentation catheter care was being provided every shift.On 05/21/2026 in the afternoon, the Unit Manager acknowledged physician orders were not followed when R2 was observed to have a 16 French catheter while the order was for a size 18 French. The Unit Manager could not speak as to why orders for catheter care every shift were not transmitted to the residents' medication administration record (MAR) so there was no documentation this was being provided routinely every shift.On 05/21/2026 at 10:31 AM, the Director of Nursing (DON) confirmed physician order were not followed based on the Unit Manager's direct observation of R2 having a 16 French Foley catheter. The DON confirmed there was no documentation of the resident's Foley catheter removal and insertion as well as routine catheter care. The DON explained documentation of catheter care did not transmit to the MAR because of an error in entering the batch order which stated, no documentation requirements. According to the DON, the resident was placed at risk for a urinary tract infection (UTI) and other catheter-related complications.The facility's Indwelling Urinary Catheter Foley Management reviewed 09/04/2025, documented based on comprehensive assessment of a resident, the facility must ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan and resident's choices. Refer to [NAME] Procedural Guidance on routine care.The Lippincott procedure: Indwelling Urinary Catheter Removal and Insertion policies (undated), outlined documentation requirements to include, indication for use, assessment findings, date and time of procedure, urine characteristics, any complications, size and type of catheter and amount of sterile water in the catheter balloon.

Based on observation, interview, record review and document review, the facility failed to ensure care and management orders were entered for a resident who was admitted with an intravenous (IV) line for 1 of 40 sampled residents (Resident 171). The deficient practice placed the resident at risk for infection.Findings include: Resident 171 (R171) was admitted on [DATE], with diagnoses including traumatic subdural hemorrhage and unspecified dementia.On 05/18/2026 at 10:38 AM, a midline with single lumen and purple port was observed on R171's left upper arm with dressing dated 05/08/2026. There was no IV pole or pump observed in the room.The medical record lacked documented evidence R171's IV line was identified by the admission nurse, clarification orders were obtained from the physician, and care orders were transcribed into the medical record.On 05/18/2026 at 10:40 AM, the Licensed Practical Nurse (LPN) confirmed R171 had a left upper arm midline dated 05/08/2026. The LPN indicated the resident was admitted to the facility on [DATE] which meant the IV line was inserted at the hospital. The LPN reviewed R171's electronic health record (EHR) and confirmed the admitting nurse failed to identify the resident's IV line, obtain clarification from the physician on whether to keep or remove the line and care and maintenance orders of the IV line would be removed. The LPN indicated consequences of midline with no care orders was infection. On 05/19/2026 at 10:30 AM, the Infection Preventionist (IP) explained when a resident was admitted with a peripheral line, the admitting nurse should remove the line since they were meant for short term use. If the resident was admitted with a midline, the nurse would obtain clarification orders from the physician on whether to maintain or remove the line. If the order was to keep the midline, care orders to include site assessment every shift, weekly dressing changes and flushing must be entered into EHR. The IP stated consequences of not following facility policy for IV lines placed residents at risk for infection. On 05/20/2026 at 12:15 PM, the Director of Nursing (DON) corroborated the IP's explanation peripheral lines were meant for short term use and would have to be removed on admission [DATE] if it was inserted in the hospital on [DATE]. If it was midline, the admitting nurse would have to seek clarification from the physician on whether to remove or maintain. If ordered to maintain, care orders such as site assessment, flushing and dressing changes should be entered and carried out. The DON confirmed the admission nurse failed to identify the resident's IV line in the admission assessment and there was no documented evidence clarification and care orders were obtained from a physician and transcribed into the EHR.The facility's Infusion Therapy - Intravenous Fluids policy revised 01/06/2026, revealed the facility would need to assess the resident for continued use of an IV line and contact physician for orders to discontinue or remove when no longer necessary. Dressing changes were performed every seven days or when soiled, loosened or dislodged. Documentation requirements included: indication for dressing change, date and time, appearance of catheter site, patient's response to procedure and any complications.

Based on interview and document review, the facility failed to ensure an annual performance evaluation for 2 of 2 Certified Nurse Aides (CNA1 and CNA2) was completed at least once every 12 months. The deficient practice had the potential to limit the facility's ability to evaluate competency, identify training needs and allow performance deficits to go unaddressed. Findings include:CNA 1 was hired on 02/15/2005.CNA 2 was hired on 01/09/2008.A review of information gathered from the Payroll Coordinator revealed the annual performance evaluations were not available for CNA1 and CNA2.On 05/20/2026 at 9:28 AM, the Payroll Coordinator explained certified nurse aides completed training and a competency evaluation prior to hire and received a performance review annually.On 05/20/2026 at 12:13 PM, the Payroll Coordinator could not verify if an annual performance review had been completed, or when the last evaluation was conducted for CNA1 and CNA2 since the date of hire.On 05/21/2026 at 8:19 AM, the Director of Staff Development (DSD), explained CNA performance evaluations were conducted annually.On 05/21/2026 at 9:34 AM, the Executive Director (ED), stated the expectation was to have the DSD and the payroll coordinator work together to be sure the facility was in compliance with state and federal regulations with all facility training and onboarding. The ED explained the staff evaluation expectation was that evaluations were done routinely and time was spent with the employees reviewing their performance over the prior year, and as needed.The facility policy titled Area of Focus: Performance Evaluations, dated 12/04/2025, documented annual performance reviews were given to all associates.The facility's policy titled Employment File Guidelines, dated 10/20/2025, documented a list of employment documents and signed policies that should be found in a typical associate personnel file. The list included performance evaluations.

Based on interview, record review and document review, the facility failed to ensure 1) indication for use for psychotropic medications were appropriate 2) side effect and behavior monitoring was in place 3) an informed consent was obtained for psychotropic medication use and 4) an Abnormal Involuntary Movement Scale (AIMS) Assessment was conducted for 1 of 40 sampled residents (R174). The deficient practiced placed the resident at risk of unnecessary medication use and potential adverse side effects. Findings include: Resident 174 (R174) was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, personal history of traumatic brain injury, and history of transient ischemic attack. Physician orders dated 05/17/2026 documented Buspirone Hydrochloride (a medication used to treat anxiety) 5 milligrams (MG) by mouth two times a day for altered mental status, and Quetiapine Fumarate (an atypical antipsychotic used to treat schizophrenia, bipolar disorder, and major depression) 25 MG one tablet by mouth two times a day for anxiety. R174's medical record lacked documented evidence of psychotic medication monitoring for behaviors or side effects related to the use of Buspirone Hydrochloride and Quetiapine Fumarate. R174's medical record lacked signed consents for the use of Buspirone Hydrochloride and Quetiapine Fumarate.R174's medical record lacked an AIMS Assessment. On 05/21/2026 at 12:38 PM, a Licensed Practical Nurse (LPN) explained when a resident admits to the facility with psychotropic medications the nurse would obtain a consent with signature. residents receiving psychotropic medications would have side effects and behavioral monitoring orders for each shift. The LPN explained residents receiving anti-psychotic medication would not have an AIMS assessment however the nurse would monitor the resident for shaking, dyskinesia (uncontrollable and involuntary movements), eyes twitching and mouth movements that may be abnormal and not related to a diagnosis the resident already presented with.On 05/21/2026 at 12:48 PM, the Director of Nursing (DON) explained the expectation for residents admitting to the facility with psychotropic medication would be for the nurse to obtain signed consent upon admission. The DON expressed nurses would enter psychotropic medication monitoring for side effects and behaviors which were required for each shift. If a resident had an anti-psychotic medication an Abnormal Involuntary Movement Scale (AIMS) Assessment would be conducted the following day.On 05/21/2026 at 12:52 PM, The DON reviewed R174's medical record and confirmed the documented indication of altered mental status for Buspirone Hydrochloride and anxiety for Quetiapine Fumarate were not appropriate, the record lacked side effects and behavior monitoring, informed consent was not obtained upon admission, and an AIMS assessment had not been completed.The facility policy titled Psychotropic Medication Management, reviewed 12/02/2025, documented the following:-The resident medical record must show documentation of adequate indications for the medication's use and the diagnosed condition for which a medication was prescribed. -A consent was required for each medication-Evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms, in order to identify the underlying cause, including adverse consequences of medications: Abnormal Involuntary Movement Scale (AIMS) Assessment tools would be used for all antipsychotic medications. -Monitoring of medications for efficacy and adverse consequences.

Based on observation, interview, and document review the facility failed to ensure the kitchen was maintained in a sanitary manner. The deficient practice placed residents at risk for foodborne illness.Findings include:On 05/18/2026 at 7:35AM, a kitchen tour was conducted with the Dietary Manager. Food debris and spillage were present on floor throughout the kitchen area specifically under the steam table, under the three-compartment sink, in the dry food storage area, and floor of walk-in freezer and refrigerator. The Dietary Manager acknowledged the debris and spillage and explained the floors needed to be cleaned. On 05/19/2026 at 1:51 PM, the Dietary Manager explained cleaning of the kitchen floors occurred at change of shift and again at night for closing of the kitchen. The cleaning of the kitchen floors consisted of sweeping and no rinse mopping. The Dietary Manager acknowledged there was lot of miscellaneous buildup, debris and spillage on the kitchen floors. The facility policy titled Prevention of Cross Contamination, reviewed 05/01/2025, documented all floor surfaces must be mopped daily and as needed using a bucket with water and appropriate floor cleaner. The facility policy Cleaning Schedule, revised 04/30/2025, documented the Director of Food and Nutrition Services shall develop a routine cleaning schedule to ensure the Food and Nutrition Services department was maintained in a clean and sanitary manner.

Based on observation, interview, record review and document review, the facility failed to ensure orders for physical therapy (PT) and occupational therapy (OT) were followed for 3 of 40 sampled residents(Residents 63, 73 and 169) and speech therapy (ST) for 1 of 40 sampled residents (Resident 48). The deficient practice placed the residents at a potential for slower progression towards goals.Findings include: Resident 63 (R63) was admitted on [DATE], with diagnoses including morbid obesity, acute respiratory failure with hypoxia and osteoarthritis. On 05/18/2026 in the morning, R63 reported missing two PT sessions on 04/10/2026 and 04/28/2026. According to the resident, the session for 04/28/2026 was rescheduled for 05/02/2026 but no staff member showed up. On 05/20/2026 in the morning, the Director of Rehabilitation services (DOR) explained R63 was evaluated for PT and OT on 04/06/2026 and was scheduled to receive five PT and five OT sessions per week. The DOR confirmed R63 missed two PT sessions on 04/10/2026 and 04/28/2026. The second session was rescheduled for 05/02/2026 but no one showed up due to short staffing. Resident 73 (R73) was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease and age-related osteoporosis. On 05/18/2026 at 9:14 AM, R73 reported having issues with therapy not being provided as scheduled. On 05/20/2026 in the morning, the DOR indicated R73 was admitted on [DATE] and was evaluated for PT and OT on 05/02/2026. R73 was scheduled to receive five PT and three OT sessions per week. The DOR confirmed a PT session was missed on 05/05/2026 due to short staffing and R73 refused a PT session of 05/08/2026. Resident 169 (R169) was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease. On 05/18/2026 in the morning, R169 reported not getting therapy services. On 05/20/2026 in the morning, the DOR indicated R169 was admitted on [DATE] and was evaluated for PT and OT on 05/14/2026. According to the DOR, R169 was scheduled to receive five PT sessions and three OT sessions per week. The DOR confirmed missed a PT session on 05/17/2026 due to low staffing on weekends. On 05/20/2026 at 11:43 AM, the DOR explained the facility had 109 residents on the census and there were 97 residents on the therapy case load. The DOR indicated the Rehab team was down a full-time OT, a full-time PT assistant, and a full-time OT assistant. The DOR acknowledged the rehab staff were challenged with current case load and delivering therapy prescriptions. On 05/20/2026 at 11:51 AM, the DOR verbalized consequence of residents missing therapy impaired the resident's rehabilitation process and placed the residents at risk for slower progress towards goals. The facility's Rehabilitation Orders policy revised 12/23/2025, documented rehabilitation services were delivered per physician's orders. Resident 48 (R48) was admitted to the facility on [DATE] with diagnoses including encounter for surgical aftercare, malignant neoplasm of tongue, dysphagia, and malnutrition. A speech therapy (ST) encounter note dated 05/05/2026 documented an evaluation was completed and a plan of treatment was developed with a recommendation for two ST sessions per week. On 05/18/2026 at 9:34 AM, R48 indicated they had not received ST as ordered. R48 explained therapy was needed to be able to eat orally. A May 2026 schedule log for therapy services documented R48 was scheduled for ST on 05/05/2026, 05/07/2026, 05/14/2026 and 05/15/2026. A service log matrix dated from 05/01/2026 to 05/31/2026 documented R48 received ST on 05/05/2026 and on 05/07/2026. ST was not performed on 05/14/2026 and 05/15/2026. On 05/20/2026 at 10:56 AM, the Director of Rehabilitation (DOR) explained upon evaluation, ST was determined based on the resident diagnosis. During evaluation a plan of care would be determined and discussed. The DOR indicated R48 was evaluated and ST ordered for two times per week and to have puree meals with speech therapist assistance. The DOR R48 was seen twice in the first week but due to a staffing issue the full-time speech therapist and the two PRN speech therapists were unavailable to work. The DOR acknowledged the current rehab staff was challenged with current case load and delivering therapy prescriptions. The DOR verbalized the consequence of residents missing therapy was impaired results and risk for slower progress towards goals.

Based on interview, record review, and document review, the facility failed to ensure a discharge was completed including a home health referral was accepted by an agency prior to discharging for a resident requiring wound dressing changes for one of five sampled residents (Resident 2). The deficient practice placed the resident at risk for wound complications including infection. Findings include: Resident 1 (R1) was admitted on [DATE] with diagnoses of cellulitis of right lower limb and polyneuropathy.A physician's order dated 04/01/2026 documented the resident may to discharge home on [DATE] and follow up with their primary care physician in one week. The order indicated the resident may go home with current medications on hand. Staff were to provide instruction on medication administration. Home Health services were ordered, including occupational therapy, physical therapy, and nursing for wound care evaluation and treatment.Instructions to cleanse the chronic wound on the left ankle with normal saline, pat dry, apply honey gel, and cover with a dry or foam dressing. The open wound on the right lower extremity and right dorsal foot were to be cleansed with normal saline, patted dry, treated with xeroform, and covered with an abdominal pad secured with Kerlix and a tubular net.The medical record revealed a notice of Medicare non coverage (NOMNC) was completed and signed by the resident on 04/01/2026 with a service end date of 04/03/2026.A discharge summary note dated 04/04/2026 indicated the resident was discharged at 11:30 AM and left with all medications and belongings. The nurse indicated all paperwork was signed and education provided regarding medications; and was understood by the resident. The discharge summary noted documented the resident left with a family member. A social services note entered by the social services assistant on 04/06/2026 indicated the case manager received a voicemail stating the home health and durable medical equipment which was referred to had been denied due to insurance being out of network. The note documented that the resident would need to follow up with their primary care provider, since all places where the referral had been sent did not accept the insurance.On 04/04/2026 at 9:20 AM, the Social Services Director verbalized the social services department worked with the case manager for discharging residents and helped to set up resources for residents as needed when discharging. The Social Services Director indicated the case managers would set up any home health care needs and should have verified acceptance of the resident from the home health agency prior to discharge.On 04/04/2026 at 9:26 AM, a Social Services Assistant (SSA) working as a case manager explained being responsible for discharge planning and would generally see the residents within 24 hours of admission. The SSA indicated the case manager would have interdisciplinary meetings with all services involved with resident care as well as the insurance case manager.The SSA revealed the facility did not wait until a resident was accepted by a home health agency prior to discharge. The SSA indicated if the resident was not accepted the facility would contact the resident and advise them to follow up with their primary care physician. The SSA explained it was the same process regardless of the reason home health was requested. On 04/13/2026 at 10:41 AM, R1 indicated being discharged without any durable medical equipment (DME). R1 was told they would have a walker, but it was not provided. The facility told R1 they would have home health, but as of 04/13/2026 the home health agency had not made a visit or contacted R1. R1 verbalized having a conversation with the insurance company and reported that no home health had been approved. As of 4/13/2026, R1 indicated no home health had come to provide care. R1 still had dressings dated 04/04/2026 and indicated they would be seeing their primary care physician (PCP) later today.R1 indicated having right foot cellulitis past the ankle, and a left foot bandage on the ankle, with no other wounds except to the bilateral feet. R1 had not had a full shower due to not wanting to wet the bandages and risk infecting the wounds. No one from the facility had called to check on the R1's welfare or whether the DME or home health had come.On 04/13/2026 at 10:54 AM, R1 indicated they were walking without a walker and holding on to walls or furniture, which placed them at risk for falls. R1 was discharged on 04/04/2026 (a Saturday) and contacted the insurance company on 04/06/2026 (a Monday). The insurance representative explained if R1 required any DME, such as a walker, it should have been discussed during the IDT meetings scheduled every Monday and Thursday. DME would need to be arranged or purchased from an approved vendor. The insurance company had its own home health services, and the home health agency (HHA) would need to be approved by the insurance company. Since R1 was discharged on a Saturday, no care meeting occurred on Thursday, and no DME and home health services were arranged.On 04/13/2026 at 11:16 AM, a Case Manager (CM1) indicated home health was arranged by the insurances healthcare provider system. CM1 indicated the insurance was aware of the discharge and had the responsibility for setting up home care. CM1 indicated working mostly with healthcare provider system. On 04/13/2026 at 11:28 AM, a Case Manager (CM2), indicated the home health agency would call the residents within 24-48 hours, and if not, the residents were advised to contact their primary care physician to set up services. CM2 reported receiving a call from R1 indicating home health had been denied. CM2 indicated they received authorization from insurance for stay and sent out referrals for home health with authorization. CM2 indicated R1's insurance issued the notice of Medicare non-coverage and determined the resident no longer was covered. CM2 reported education was provided on the process of appeal and the family member was informed.On 04/13/2026 at 12:40 PM, a Physical Therapist (PT) familiar with R1 indicated the resident had a walker in their room which was provided by the facility. R1 was independent to walk short distances but a walker was recommended for distances 150 ft and beyond. Once the recommendation was made by therapy, the discharge planners took over.The PT Discharge summary dated [DATE] to 04/03/2026, revealed R1's baseline ambulation level was supervision with touching assistance and progressed to independent at discharge on [DATE]. Discharge recommendations included home health services, and a two-wheeled walker assistive device. Discharge to prior living arrangement which was a private residence.On 04/13/2026 at 2:21 PM, a SSA indicated the best practice would have been to wait until a home health agency had accepted the resident before discharging. The SSA explained having received notification on the day of discharge the referral for home health or DME was not accepted. The only way to get around the delay from insurance would have been to appeal immediately. Provide education regarding following up with the primary care physician and give option to remain at facility for out of pocket due to not being able to find home health agency.The SSA indicated the resident had been authorized by insurance for the stay at the facility and was the insurance on record. The insurance required the resident to be discharged by 04/04/2026. Prior to discharge, the home health agency which should have been in network based on the insurance information was sent as a referral, contacted the facility to inform the resident was denied due to being out of network. The SSA explained there had been confusion with the insurance regarding what services were considered in-network. The insurance used for the facility stay differed from the unit responsible for home health, resulting in home health agencies denying services and indicating the resident was out of network.On 04/13/2026 at 3:09 PM, a wound care nurse revealed the discharge process would have included a consult with SSAs to make the determination if the resident needed to be followed for wound care after discharge. The wound care nurse indicated R1 should have been followed up by an outpatient wound care provider for treatment. The wound care nurse indicated complications could have occurred for missed wound dressing changes including the possibility of further infection, worsening of cellulitis.On 04/13/2026 at 4:37 the SSA clarified when a resident was admitted , the admission department determined what the resident was at the facility for, the business office verified, and social services took over from there. Clinical records were sent to insurance provider for a week, usually every seven days and the insurance decided the last covered date based off the resident's progress or need for skilled services. The SSA indicated having meetings with insurance case managers two times a week (Monday and Thursday) with the IDT team to include providers, the insurance case manager and the facility case manager, the Director of Nursing (DON). R1 was under straight Humana who authorized her stay. On 04/13/2026 at 4:40 PM, the DON indicated physician orders were required plus therapy discharge notes to discharge a resident. The DON indicated the discharge planning process started on admission where discharge goals were identified including support systems, any DME needed, services such as wound care, etc. Physicians wrote the discharge summary, case managers were in touch with the insurance providers, and the facility was required to notify the Ombudsman on discharges for residents who were not competent to make their own decisions and had no support system. If residents were alert, self-responsible, had their own residence, and family support, the Ombudsman did not need to be notified. On 04/13/2026 at 4:50 PM, the DON and the SSA indicated R1's discharge was an insurance-driven discharge, Insurance Company's Name messed this up. The SSA explained R1's right to appeal and R1 insisted on going home. R1 was told the cost for private pay would have been $600 per day for room and board. R1 told the SSA they wanted to go home with wound services. The DON indicated unfortunately they call the shots.The medical record lacked documented evidence of the conversation regarding no home health acceptance with the resident or any refusal by resident to stay under private pay.On 04/13/2026 at 5:03 PM, the SSA indicated when a resident discharged , one of the discharge instructions was to contact the facility if home health or DME or any concerns were encountered. R1 called the insurance company, and the facility was notified R1 was declined home health services due to the insurance being out of network. The SSA indicated the facility usually did not do well calls for discharged residents, except for residents who left against medical advice. The social service department continued to search for home health agencies who could accept R1, but facility had not succeeded.The facility policy titled Discharge Planning Process (revised April 2025) documented the discharge planning process would address each resident and the discharge goals and needs including caregiver support and referrals to local contact agencies as appropriate. The discharge plan would identify the discharge destination and ensure it meets the health and safety needs as well as preferences. Complaint 2978689

Based on observation, interview, record review, and document review, the facility failed to ensure scheduled showers were provided for residents who were assessed to require assistance with showers for 3 of 5 sampled residents (Residents 3, 4 and 5). The deficient practice had the potential to negatively impact on the residents' quality of life.Findings include:Resident 3 (R3) was admitted on [DATE], with diagnoses including displaced fracture of lateral malleolus of right fibula, subsequent encounter for closed fracture with routine healing and sprain of the superior tibiofibular joint and ligament and right knee.The admission minimum data set (MDS) dated [DATE], revealed R3 had intact cognition and required substantial/maximal assistance for bathing.On 04/13/2026 at 7:55 AM, R3 lay in wheelchair wearing night gown and reported being told their shower days were scheduled for Wednesdays and Saturdays on day shift. R3 reported they had only been provided two showers since admission. R3 indicated looking forward to showers and would not refuse one nor would the resident allow a bed bath to replace a shower. The Shower schedule revealed R3's showers were scheduled for Wednesdays and Saturdays by day shift. On 04/13/2026 at 9:44 AM, the Unit Manager (UM) went through the resident's shower sheets and indicated R3 who was admitted on [DATE] had two documented showers on 04/04/2026 and 04/08/2026. The UM indicated R3 appeared to have refused a shower on 03/28/2026 and 04/11/2026 and received a bed bath on 04/01/2026, 04/02/2026 and 04/06/2026. The UM indicated if R3 stated they would not refuse a shower and would always opt for a shower versus a bed bath then the medical record would show R3 had only been provided with two showers on 04/04/2026 and 04/08/2026.On 04/13/2026 at 3:00 PM, the Director of Nursing (DON) reviewed R3's activities of daily living (ADL) bathing report which revealed R3 received showers on 04/04/2026 and 04/08/2026 and appeared to not have missed bathing since bed baths were given on 04/01/2026, 04/02/206 and 04/06/2026 and reflected R3 refused showers on 03/28/2026 and 04/11/2026.On 04/13/2026 at 3:22 PM, the DON was in R3's room when R3 verbalized looking forward to showers especially since there were only two showers scheduled every week. R3 indicated preferring a shower over a bed bath and pointed to bed and stated, I have never received a bath on this bed. R3 emphasized not refusing a shower on 03/28/2026 but acknowledged refusing one on 04/11/2026 since the certified nursing assistant (CNA) offered to shower the resident late in the day and the CNA was reaching end of shift.On 04/13/2026 at 3:26 PM, R3 listened as the DON confirmed a shower was documented as refused on 03/28/2026 but R3 denied being offered a shower at all on 03/28/2026. The DON indicated the ADL report showed R3 was provided with bed baths on 04/01/2026, 04/02/2025 and 04/03/2026, R3 interrupted and told the DON this was not true and reiterated the resident had not had a bath while in bed. The DON confirmed the resident's report of showers did not align with medical record.Resident 4 (R4) was admitted on [DATE] and readmitted on [DATE] with diagnoses including ischemic cardiomyopathy, atrial fibrillation and diabetes mellitus.The admission MDS dated [DATE], documented R4 had intact cognition and required partial/moderate assistance with bathing.On 04/13/2026 at 8:10 AM, R4 indicated missing showers.The Shower schedule revealed R4's showers were scheduled for Mondays and Thursdays on day shift. On 04/13/2026 at 9:51AM, the UM indicated R4 was admitted on [DATE] and readmitted [DATE]. The UM reviewed R4's ADL bathing report and indicated R4 missed a scheduled shower on 04/03/2026 with no documented evidence of refusal or re-offer.On 04/13/2026 at 3:01 PM, the DON confirmed R4 missed a scheduled shower on 04/03/2026.Resident 5 (R5)R5 was admitted on [DATE], with diagnoses including Parkinson's disease.The admission MDS dated [DATE], revealed R5 had moderately impaired cognition and was totally dependent on staff for showers.On 04/13/2026 at 8:20 AM, R5 sat up in bed with breakfast tray in front. R5 indicated being in the facility for two weeks and had not gotten a shower.The Shower schedule document revealed R5's showers were scheduled for Tuesdays and Fridays on day shift. On 04/13/2026 at 9:44AM, the UM reviewed R5's ADL bathing report and confirmed R5 missed a scheduled shower on 04/07/2026 due to a room change and missed another shower on 04/10/2026 with no documented reason.On 04/13/2026 at 3:02 PM, the DON confirmed R5 had a missed shower 04/10/2026 but a bed bath was provided on 04/08/2026 after a scheduled shower was missed on 04/07/2026. The facility's ADL Service Assistance policy revised 08/25/2022, documented personal care would be provided to all residents according to findings from the move-in evaluation. Residents were to have a full shower/bath, according to their needs and preferences at least twice per week.Complaint 2712783

Based on interview, record review and document review, the facility failed to ensure a physician order for computed tomography (CT) scan was carried out for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to delay or negatively impact the resident's plan of care.Findings include: Resident 1 (R1) was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.A physician order dated 12/10/2026, documented to have CT scan (a fast, non-invasive imaging procedure which uses X-rays to create detailed three-dimensional images of bones, organs and tissues) to exclude ascending aortic aneurysm.The medical record lacked documented evidence R1's CT scan was completed.On 04/13/2026 at 1:17 PM, the Unit Manager explained diagnostic procedures which could be done inside the facility including X-rays, kidney, ureter, bladder (KUB), and electrocardiogram (EKG). Procedures which could not be done in the facility and would need to be scheduled with an outside provider included CT scans, magnetic resonance imaging (MRI), and barium swallow tests. The Unit Manager explained once a physician order was obtained for a CT scan, a nurse would complete an appointment request form which would be handed over to case management be responsible for scheduling the procedure.On 04/13/2026 at 1:20 PM, the Unit Manager acknowledged personally entering R1's order for a CT scan into the resident's medical record but forgot to complete an appointment request form and this order was not communicated to case management. The Unit Manager confirmed the physician order for R1's CT scan dated 12/10/2025 was not carried out.On 04/13/2026 at 2:36 PM, the Director of Nursing (DON) confirmed the missed CT scan for R1 was an oversight.The facility's Diagnostic Services policy reviewed 09/23/2025, documented the facility would ensure diagnostic services would meet the needs of the residents and the facility would be responsible for quality and timeliness of services whether services were provided by the facility or an outside resource. The results would be reported timely to the ordering physician to address potential concerns, disease prevention, diagnosis and treatment.Complaint 2712783

Based on observation, interview and document review, the facility failed to properly date resident drink containers in 2 of 2 nourishment refrigerators and employee food stored in the resident freezer. This deficient practice has the potential to lead bacterial growth and foodborne illnesses. Findings include: On 06/10/2025 at 8:37 AM, in the nourishment refrigerator located on the 100 and 200 hall there were three containers of juice, which had no start or end dates. On 06/10/1025 at 8:38 AM, the nourishment freezer contained employee personal food items which included a TV dinner, breakfast burrito, yogurt, strawberries, and an ensure. On 06/10/2025 at 8:42 AM, in the nourishment refrigerator located on the 300 and 400 hall there was one container of apple juice, which had no start or end date. On 06/10/2025 at 8:44 AM, the Kitchen Director, stated food and drink items should be dated with a start and end date before items are placed in the refrigerator and employees are not allowed to store personal food items the resident's nourishment refrigerators. On 06/12/2025 at 11:45 AM, the Registered Dietitian clarified any food or drinks placed into the nourishment refrigerator is labeled with a start and end date and employees are not allowed to store food in the resident's nourishment rooms. On 06/13/2025 at 8:18 AM, facility undated policy titled, Use by date guide documented, all open containers of food in the dry storage area should be placed in an enclosed container, labeled and dated with the open date and the use by date. On 06/13/2025 at 1:48 PM, facility policy titled food safety dated 05/01/2025, documented associate food will not be stored with resident food.

Based on observation, interview, record review and document review, the facility failed to maintain dignity for 1 of 24 sampled residents (Resident 362). The deficient practice had the potential to result in unnecessary disclosure of resident care needs and failed to promote respect and individuality. Findings include: Resident 362 (R362) R362 was admitted on [DATE] with diagnoses including metabolic encephalopathy, muscle weakness, and atrial fibrillation. On 06/10/2025 at 9:19 AM, a handwritten sign posted on the wall above R362's bed documented Feeder Please. A Physician order dated 05/30/3035 documented one to one assistance with meals. The admission Minimum Data Set (MDS) dated [DATE] documented R362 required maximal assistance with eating: (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). On 06/11/2025 at 8:26 AM, a Certified Nurse Assistant (CNA) acknowledged the handwritten sign posted on the wall above R362's bed and explained the sign indicated R362 needed assistance with eating. The CNA explained usually the signage would be a typed or printed sign from the Speech Therapy (ST) department and it would indicate the need for assistance and would have instructions with the type of assistance to provide. On 06/11/2025 at 9:51 AM, The Director of Rehab (DOR) explained signage placed above a resident's bed would be initiated by ST if the resident was on ST services and would require a focus on optimal swallowing, if not a swallowing related issue and the resident was only requiring assistance to maintain optimal intake or assistance physically with a meal, it would fall to nursing for assistance. The DOR explained a sign indicating Feeder Please would not be an appropriate sign to place. The DOR explained staff would use first person acknowledgment to maintain resident dignity. On 06/11/2025 at 9:58 AM, a Registered Nurse (RN) explained R362's spouse placed the sign above R362's bed to ensure staff provided assistance with meals. The RN explained the sign was not appropriate and should be replaced with a more appropriated sign to indicate R362 required assistance. The RN explained the sign was not respectful to the dignity of the resident by indicating feeder. On 06/13/2025 at 7:56 AM, a CNA was preparing to enter R362's room with a meal tray when stopped by another CNA who stated R362 was a feeder and to wait on the tray until staff were able to assist. On 06/13/2025 at 12:58 PM, the Director of Nursing (DON) explained R362's family wanted the sign placed. The DON explained staff could have addressed R362's family wishes in a better way by getting ST involved to assist with creating and implementing another sign noting the assistance R362 required with meals. The DON further explained the staff would then be able to explain to R362's family the need to replace the sign. The DON explained the expectation for staff communication was to not refer to residents as feeders instead the DON would expect the staff to utilize a more dignified statement to state R362 required assistance with meals. The facility policy titled Dignity, with review date 09/26/2024, documented all residents would be treated with dignity and respect. Examples of treating residents with dignity and respect include but are not limited to addressing residents by the name or pronoun of the resident's choice, avoiding the use of labels for residents such as feeders or walkers.

Based on interview, record review, and document review, the facility failed to ensure an incident of resident elopement was reported to the State Agency (SA) within the required timeframe for 1 of 24 sampled residents (Resident 84). The deficient practice had the potential to place residents at risk for further incidents and to not be adequately protected. Findings include: Resident 84 (R84) R84 was admitted on [DATE] with diagnoses including dementia, and displaced fracture of left tibia. On 06/09/2025 the State Agency received an anonymous complaint alleging the facility had a resident elopement from the facility which was not reported as required. On 06/12/2025 at 1:00 PM a Certified Nursing Assistant (CNA) verbalized during shift change, the CNA would walk down hall with previous CNA and updates were given regarding residents. The CNA explained the front inside automatic door was always locked and would have to be buzzed out or press button on wall adjacent to the front door prior to doors opening. The CNA indicated wander guards was a device used to alert staff of a resident walking near the exit doors and an audible alarm would go off when the resident wearing a wrist or ankle bracelet was within a few feet of exit and generally would be used for confused residents and not residents with intact cognitive awareness. The CNA revealed residents at risk for elopement or residents with wandering or exit seeking behaviors were given a wander guard. The CNA verbalized the wander guard was a single use band as it would have to be cut off to be removed, the nurse would apply the wander guard. Once a resident was fitted with a wander guard the information would be put in a binder and kept at the nursing station. If a resident were to leave the facility without notifying a staff member it would be considered an elopement and code pink would be called overhead and staff would begin searching for resident. On 06/12/2025 at 1:13 PM, the Unit Manager indicated rounds were conducted as often as possible, generally every 30 minutes residents were at least observed between the CNA and nurses overlapping rounds. The Unit Manager verbalized the only exit from the building was at the front where there were two automatic doors. The interior door was always locked, and a staff member was at the front desk to buzz people in and out until 8:00 PM. After 8:00 PM anyone entering would have to ring the bell and nursing staff had a monitor of camera view of the front door and could buzz person inside. The unit manger explained wander guards were used for residents who were difficult to redirect, had exit seeking behaviors, and were impulsive with decision making. Wander guards required a physician order to be applied. The wander guard could not be pulled off or unsnapped once applied, it had to be cut off. The Unit Manager explained there was an elopement binder at the nursing station and front desk which includes a photo of residents who have wander guard in place. R84 did not speak English and would require staff to call interpreter or use staff who spoke Korean in order to adequately communicate with resident. The Unit Manager explained R84 would frequently walk in secured courtyard however one day went outside when the front door was open. The Unit Manager verbalized the resident did not leave the property however the resident was given a wander guard after incident. The Unit Manager verbalized resident was frequently considered confused in assessments due to language barrier however when speaking in native language R84 was alert and oriented to person, place, time, and events. R84 had plan to be discharged on 06/06/2025 and wanted the wander guard removed the previous night. The Unit Manager explained there was no discharge order yet primarily because the facility needed to wait until R84's friend came to building to pick up R84 in order to get details of where R84 was going. The Unit Manager indicated sometime after 9:00 or 10:00 PM resident was noted to be missing, and code pink was called for elopement, the executive director was notified, and the police were contacted. The resident was never found and was discharged from facility system. On 06/12/2025 at 1:47 PM, the Social Worker explained a cognitive assessment was conducted after admission using a translator. On 06/12/2025 at 2:07 PM, a Case Manager indicated R84 was Korean speaking and did not understand English and would use language service to communicate with resident. The CM explained the discharge plan was for R84 to discharge with friend however had to wait until day of discharge to speak with R84's friend to get details on where the resident would be living. The CM explained a different CM was primarily handling case with R84 and had previously spoke to R84's friend. The CM verbalized all communication with family or friends regarding discharge should be documented in the medical record however there were no notes regarding any communication with friend. There was no discharge order entered as the facility was waiting until day of discharge to discuss with R84's friend. The CM confirmed resident leaving the facility would not be considered a discharge and if it was a case of leaving against medical advice (AMA) it would generally still give the facility an opportunity to discuss risks associated and was not the case with R84. On 06/12/2025 at 2:27 PM, Unit Manager indicated being able to speak Korean and was occasionally used to interpret for R84. The Unit Manager explained being able to communicate well with resident in Korean and English however it appeared as though resident could understand English and would need to respond in Korean in order to be fully understood. On 06/13/25 at 11:00 AM, the Director of Nursing (DON) explained R84 should have interpreter with all staff not able to communicate in Korean. The DON indicated the facility would not usually give resident wander guard for alert and oriented and should not have been given wander guard and felt it was an overreaction from nurse due to previous incident with another resident eloping from facility. The DON confirmed the process for obtaining a wander guard would be to get order from physician, monitor every shift the wander guard was in place. and add in the care plan. The DON acknowledged there was no order for wander guard however there was a note in the electronic health record notifying the physician. On 06/13/2025 in the afternoon, the Executive Director (ED) indicated the resident was officially discharged since R84 was scheduled to be discharged the following day and did not consider it an elopement. The ED explained the police were notified because all contact information for R84 did not produce any results. The ED verbalized understanding the resident did not have discharge order or any evidence the resident was considered leaving against medical advice. The ED indicated had spoken to member from corporate team and it was determined it did not meet the facility reporting standards however was not able to say if incident was considered a safe discharge, leaving against medical advice, or an elopement. There was no record the State Agency was notified of elopement from facility for R84. The facility policy titled Elopement (revised 11/19/2024) documented elopement occurs when a resident leaves the premises or a safe area without authorization such as an order for discharge. Complaint NV00074431

Based on observation, interview, record review and document review, the facility failed to ensure a resident baseline care plan fit the needs for 1 of 24 residents. The deficient practice had the potential to significantly impact the resident's well-being and safety. Findings include: Resident 316 Resident 316 (R316) was admitted on [DATE], with diagnoses of altered mental status. On 06/10/2025 at 2:15 PM, observed the resident calling out for assistance in Spanish and did not understand how to utilize the call light. On 06/11/2025 at 1:25 PM, a Certified Nursing Assistant (CNA), stated the resident is confused and not aware of the surroundings. The CNA voiced the resident does not understand how to utilize the call light and expressed the resident screams for assistance in Spanish. The CNA entered into the resident's room and asked the resident to push the call light button and verified the resident did not understand how to use the call light. On 06/11/2025 at 1:42 PM, a Licensed Practical Nurse (LPN), expressed when a confused resident is newly admitted the nurse and CNA would orientate the resident into the room, frequent reminders on how to utilize the light, continuous rounding and update the care plan. The LPN clarified the resident should be close to the nurse's station and verbalized the current call light is not suitable and should be exchanged to the press pad. On 06/11/2025 at 2:08 PM, the Unit Manager (UM), stated the resident was admitted on [DATE] and is alert and orientated times four. The UM explained the facility has Spanish speaking staff and can interpret. The UM expressed confused residents would have frequent checks, moved close to the nurse's station, the call light in reach and reminders with call light utilization. On 06/11/2025 at 2:52 PM, review of the Minimum Data Set (MDS) dated on 06/08/2025, documented the facility conducted a brief interview for mental status, the resident did not understand. An evaluation for the residents short-term and long-term memory, which indicated the resident had a memory problem. An evaluation pertaining for the resident to recall the location of the room, staff names, faces and location, the resident was not able to recall during the interview. An evaluation for the resident's cognitive skills for daily decision making indicated the resident was severely impaired. On 06/11/2025 at 3:03 PM, a skilled note dated 06/05/2025, documented upon arrival the resident is Spanish speaking who is alert and able to make needs known. On 06/11/2025 at 3:05 PM, a health status note dated 06/05/2025, documented the resident was oriented to the room, facility and how to utilize the call light. On 06/11/2025 at 3:17 PM, the care plan dated 06/05/2025, documented the resident has impaired cognitive ability, an impaired thought process and to allow extra time for resident to respond to questions and instructions. The care plan lacked documented evidence the resident was unable to utilize the call light and would call out for help in Spanish. On 06/13/25 at 7:44 AM, review of policy titled baseline care plan dated, 09/05/2024, documented the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.

Based on observation, interview, record review, and document review, the facility failed to ensure incontinent care was provided to a dependent resident who was soiled, wet, and had requested assistance for 1 of 24 sampled residents (Resident 111). This deficient practice had the potential to result in skin breakdown, infections, discomfort, and a diminished quality of life. Resident 111 (R111) R111 was admitted on [DATE] and discharged on 04/02/2025 with diagnoses including multiple sclerosis, difficulty walking, and need for assistance with personal care. On 06/04/2025 the State Agency received a report detailing concerns related to R111. The report alleged R111 had been left in a soiled incontinence brief for several hours on 03/17/2025 while at the facility. An admission minimum data set (MDS) assessment dated [DATE] documented R111: - no mobility devices - dependent on toileting - dependent with lower body dressing - dependent with mobility On 06/13/2025 at 10:00 AM, the Unit Manager indicated being familiar with incident involving R111. The Unit Manager revealed R111 had incontinence brief changed at 11:30 AM on 03/17/2025 with assistance from certified nursing assistant (CNA). At approximately 5:00 PM on 03/17/2025 the night shift CNA indicated R111 had complained of not having brief changed since the morning and had been requesting assistance. The Unit Manager explained the brief was immediately changed and it was discovered the day shift CNA had left the building for transport with another resident and did not notify the other CNAs in the building, only notifying the nurse for the unit. The Unit Manager indicated speaking with the nurse and was advised the nurse had seen the resident earlier in day for medication pass and then answered the call light later. The nurse verbalized R111 had requested assistance with changing brief and nurse obtained assistance from a CNA but did not follow up with CNA to ensure service was provided. On 06/13/2025 at 11:22 AM, the Director of Nursing (DON) acknowledged incident and verbalized it did occur. The DON explained the day shift CNA went with another resident to medical appointment and did not notify the other CNAs in the facility only the nurse on unit. The DON indicated the expectation for staff when answering call lights was for staff to provide needed services or ensure it was completed and verbalized the nurse can follow up or change resident and does not necessarily always fall on the CNA to complete. The DON further explained it was normal for nurse to turn off call light after checking on resident and notify the CNA of what was needed, however it was important the nurse return to CNA to ensure task was completed. The facility policy titled Resident Rights (revised 09/10/2024) documented residents have a right to dignified existence with access to persons and services inside and outside the facility. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment which promotes maintenance or enhancement of the quality of life. Complaint NV00074387 Facility Reported Incident NV00073739

Based on observation, interview, record review and document review, the facility failed to obtain physician orders for 2 of 24 sampled residents (Resident 84 and Resident 51) and schedule a follow-up appointment as recommended for 1of 24 sampled residents (Resident 51). The deficient practice had the potential for inappropriate discharge and to delay treatment and healing of a fracture. Findings include: Resident 84 (R84) R84 was admitted on [DATE] with diagnoses including dementia, and displaced fracture of left tibia. The medical record lacked documented evidence of a physician order to discharge for R84. The medical record lacked documented evidence of a physician order for use and monitoring of a wander guard for R84. On 06/12/2025 at 1:13 PM, the unit manger explained wander guards were used for residents who were difficult to redirect, had exit seeking behaviors, and were impulsive with decision making. Wander guards required a physician order to be applied. The wander guard could not be pulled off or unsnapped, once applied, it had to be cut off. The Unit Manager verbalized there was an elopement binder at the nursing station and front desk which includes a photo of residents who have a wander guard in place. The Unit Manager explained R84 would frequently walk in secured courtyard however one day went outside when the front door was open. The Unit Manager verbalized the resident did not leave the property however the resident was given a wander guard after incident. The Unit Manager verbalized resident was frequently considered confused in assessments due to language barrier, however when speaking in native language R84 was alert and oriented to person, place, time, and events. R84 had plan to be discharged on 06/06/2025 and wanted wander guard removed the previous night. The Unit Manager explained there was no discharge order yet primarily because the facility needed to wait until R84's friend came to building to pick up R84 in order to get details of where R84 was going. The Unit Manager indicated sometime after 9:00 or 10:00 PM, resident was noted to be missing, and code was called for elopement, the executive director was notified, and the police were contacted. The resident was never found and was discharged from facility. On 06/12/2025 at 2:07 PM, a Case Manager (CM) explained the discharge plan was for R84 to discharge with friend however had to wait until day of discharge in order to speak with R84's friend to get details on where the resident would be living. The CM explained a different CM was primarily handling case with R84 and had previously spoke to R84's friend. The CM verbalized all communication with family or friends regarding discharge should be documented in the medical record, however there were no notes regarding any communication with friend. There was no discharge order entered into computer as the facility was waiting until day of discharge to discuss with R84's friend. On 06/13/25 at 11:00 AM, the Director of Nursing (DON) indicated the facility would not usually give resident a wander guard for alert/oriented residents and R84 should not have been given wander guard and felt it was an overreaction from nurse due to previous incident with another resident eloping from facility. The DON confirmed the process for obtaining a wander guard would be to get order from physician, monitor every shift the wander guard was in place. and add in the care plan. The DON acknowledged there was no order for wander guard however there was a note in the electronic health record notifying the physician. On 06/13/2025 in the afternoon, the Executive Director (ED) indicated the resident was officially discharged since R84 was scheduled to be discharged the following day and did not consider elopement. The ED verbalized understanding the resident did not have discharge order or any evidence the resident was considered leaving against medical advice. The ED was not able to say if incident was considered a safe discharge, leaving against medical advice, or an elopement. Complaint NV00074431 Resident 51 (R51) R51 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including dysphagia, muscle weakness, and displaced fracture of surgical neck of right humerus. On 06/10/2025 at 10:32 AM, R51 explained having had a fall several months ago resulting in a fracture of the right arm and needing a sling. R51 stated never had follow- up appointments or x-ray, and the sling was gone. A Nursing progress note dated 12/07/2024 documented R51 had a witnessed fall. The CNA reported to the nurse R51 was on the floor. A Nursing progress note dated 12/07/2024 documented upon follow-up, R51 had pain localized to the right shoulder and arm. R51 was receiving pain medication. A Physician progress note dated 12/09/2024 documented R51 reported to have a fall during the weekend, Xray of right shoulders ordered, and R51 to be sent out to emergency room if Xray reports humeral fracture. An imaging report for the right upper shoulder dated 12/09/2024 documented impression of acute comminuted (bone broken into three or more pieces) and displaced fracture of the neck of the humerus. A Hospital Emergency Provider report dated 12/09/2024 documented diagnosis shoulder dislocation, humerus fracture right shoulder non-custom immobilization sling. A Physician progress note dated 12/10/2024 documented R51 returned from emergency room with recommendation of right shoulder and right upper extremity immobilization. R51 was to follow up with Orthopedics. An imaging report of the right humerus dated 01/14/2025 documented impression of humeral fracture. An Orthopedic consult note dated 01/16/2025, documented R51 to remain in the sling, follow up in four to six weeks with updated x-rays of right shoulder. A Nursing progress note dated 01/16/2025 documented R51 returned from orthopedic consult appointment for right shoulder fracture with orders to continue sling and follow up in four- six weeks. Transportation made aware. R51's medical record lacked a physician order for right shoulder sling. On 06/11/2025 at 11:50 AM, a Licensed Practical Nurse (LPN) explained when orders or requests for appointments were made an appointment request form was completed and given to case management for scheduling. Once the appointment was made the facility would transport the resident. On 06/11/2025 at 11:58 AM, a Case Management staff member explained long term care resident's appointments were coordinated with the social service department. On 06/11/2025 at 12:03 PM, the Social Services Director (SSD) explained remembering the orthopedic consult appointment for R51 and it being non-surgical interventions. The SSD reviewed the notes from R51's orthopedic appointment on 01/16/2025 and confirmed the recommendation was to follow up in four to six weeks. The DSS explained needing to review information to verify if an appointment was made. On 06/12/2025 at 8:19 AM, R51's Nurse Practitioner (NP) explained R51 was sent to another hospital for an orthopedic visit. The NP stated the fracture was not operable. The NP stated R51 wore a sling for a while and explained being unaware there was no physician order for the sling. The NP confirmed an order should have been entered for R51's sling use and an order should have been written for when the sling was discontinued. The NP was unable to explain when the sling use was discontinued and what provider instructed R51 to no longer wear the sling. On 06/12/2025 at 10:56 AM, the LPN confirmed R51's medical record lacked physicians orders for the right arm sling. On 06/13/2025 at 8:42 AM, The Unit Manager (UM) for R51's unit confirmed R51 would require an order for the sling, and it should have been entered upon return from the hospital. On 06/13/2025 at 9:10 AM, the Director of Nursing (DON), explained the expectation for a resident returning from the emergency room or hospital was for orders to be reviewed with the resident's attending physician. The orders would then be entered in the resident's medical record. The DON explained R51 would require orders for use of the sling. The DON explained residents who return with recommendations for appointments required the nurse to relay the recommendations to resident's physician and enter the orders. The DON explained for transportation arrangement the appointment form was to be completed and processed. The DON explained having reviewed R51's medical record and confirmed orders were not obtained for the use of the right arm sling and no orders were obtained to discontinue the use of the sling. The DON also confirmed the recommendation for the follow up appointment was not completed. The facility policy titled Transportation Coordination and Services, with review date 05/15/2025, documented the facility would assist residents in making necessary appointments for services not provided in the facility and arranging for transportation to and from such appointments. The facility policy titled admission Policy- Nevada Facilities, revised 01/07/2025, documented a physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

Based on interview, record review and document review, the facility failed to ensure weekly weights were obtained in accordance with physician's order for 1 of 24 sampled residents (Resident 3). The failure potentially delayed identification of a significant weight change, nutritional re-assessment by a Registered Dietitian (RD) and appropriate interventions by the inter-disciplinary team (IDT). Findings include: Resident 3 (R3). R3 was admitted on [DATE] with diagnoses including protein-calorie malnutrition and difficulty swallowing. The medical record revealed the following weights documented for R3: - on 05/20/2025 111 lbs. (pounds) - on 06/09/2025 95 lbs. Accounting for a 14.1% weight loss from 5/20/2025 to 06/09/2025. The medical record lacked documented evidence of any further weights obtained. A physician order dated 05/19/2025 documented to obtain weekly weights for one month and then monthly weights. On 06/12/2025 at 11:42 AM, a Certified Nursing Assistant (CNA) explained the CNAs on the unit were only responsible for admission weights until about two or three weeks ago. A restorative nursing assistant (RNA) was dedicated to obtaining all weekly weights. The RNA was no longer at the facility and would be advised by nursing leadership if weights were needed for residents on unit. The CNAs would not enter the weight into the electronic medical record, weight results would be given to nurse to enter. On 06/12/25 at 12:12 PM, the Registered Dietitian (RD) indicated being a contracted staff member and would normally visit facility twice per week. The RD explained once resident was admitted the RD would evaluate the resident within one week and was available by phone for staff. The RD indicated there was a meeting called if a resident was at risk and would discuss any concerns staff had about specific residents. R3 would have been discussed during the current weekly resident at risk meeting based on weight obtained on 06/09/2025. The RD confirmed the facility policy was to obtain weekly weights during the first four weeks of admission and acknowledged R3 had missing entries for weights. The RD verbalized R3 did have weight obtained during second week, however it was only written down on an internal handwritten document which demonstrated R3 had gained two pounds since admission. The RD verified R3 was at risk for malnutrition and had been started on house shake and protein supplement and indicated missing weekly weight could delay new interventions from being implemented. The RD verbalized the dietary manager was keeping track of residents requiring weights to be obtained and would notify nursing manager of any residents needing new weight measurement. The RD explained R3 was eating 50-75% of all meals. On 06/13/25 at 8:01 AM, the Dietary Manager indicated the process for documenting weights was the dietary manager would run report to see what residents were required for weekly weights. The dietary manager explained a list of residents would be given to the Director of Nursing (DON) to follow up to ensure weights were obtained. The DON would designate a nursing staff member, CNA or nurse to obtain the weight. The weight would then be obtained, and the unit manager would give the list of residents and weights back to the dietary manager and weights would then be documented in the medical record. The Dietary Manager verbalized when the weight was added to the medical record and evaluated it may be the following week. The dietary manager confirmed weight was obtained on 05/25/2025, however it was missed the following week and was not documented in the electronic health record. The dietary manager explained the process could have identified the weight loss earlier if not missed. On 06/13/25 at 10:34 AM, the Director of Nursing (DON) explained prior to two weeks ago, CNAs would get list and obtain weights, give back to dietary manager and would enter weights. and then dietitian would review. As of last week, the dietary manager will give to DON and would be divided out to the unit managers and unit managers would give to CNA on unit. The DON confirmed the facility process was under review to ensure weights were obtained and reviewed timelier. The DON acknowledged there was a weekly weight missed and could have identified significant weight loss sooner. The facility policy titled Weights and Heights (revised 09/10/2024) documented all residents were weighed within 24 hours after admission and weekly for four weeks and as needed thereafter or more as determined by the resident at risk committee.

Based on interview, record review and document review, the facility failed to administer significant medications per physician order [REDACTED]. Findings include: Resident #30 (R30) R30 was admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Care Plan initiated 03/18/19, documented R30 had a [MEDICAL CONDITION] disorder. The Care Plan indicated an intervention to give [MEDICAL CONDITION] medications as ordered by the doctor. A physician order [REDACTED]. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A physician order [REDACTED]. The MAR for (MONTH) 2019, documented [MEDICATION NAME] was not administered on 03/15/19, 03/16/19, 03/18/19, 03/21/19 and 03/22/19 for the 8:00 AM dose, and on 03/15/19, 03/20/19 and 03/21/19 for the 8:00 PM dose. The MAR indicated [REDACTED]. A physician order [REDACTED]. The MAR for (MONTH) 2019, documented Levetiracetam was not administered on 03/20/19, 03/21/19 and 03/22/19 for the 8:00 AM dose, and on 03/20/19 and 03/21/19 for the 8:00 PM dose. The MAR indicated [REDACTED]. The medical record lacked documented evidence the Attending Physician or the Nurse Practitioner was made aware R30 did not consistently receive the Lacosamide, [MEDICATION NAME] Sodium and Levetiracetam [MEDICAL CONDITION] medications. The Transfer to Hospital Summary dated 03/23/19, revealed at around 8:15 PM on 03/22/19, a Certified Nurse Assistant heard R30 produce a gurgling sound. R30's eyes were noted to have rolled back and the resident did not have control of tongue. R30 did not respond to staff calling the resident's name. R30's Oxygen saturation was 77% on room air and Oxygen was immediately started but the resident's Oxygen saturation had not gone up. The resident remained lethargic and did not respond to staff's stimulation. The Nurse Practitioner who had been at the facility at the time ordered for R30 sent to the hospital. R30 was taken to the hospital. The medical record lacked documented evidence the receiving Emergency Department at the acute hospital was informed R30 had not received several dosages of the [MEDICAL CONDITION] medications, Lacosamide (since 03/05/19), Levetiracetam (since 03/20/19) and [MEDICATION NAME] Sodium (since 03/15/19). The acute hospital's Emergency Department Physician Record Reexamination note dated 03/22/19, documented R30 would be admitted for altered mental status and brief hypoxic episode likely related to a [MEDICAL CONDITION] activity. The acute hospital's Authorization and Consent for Transfer dated 03/29/19, documented R30 would be transferred back to the facility and the following items were discussed with the receiving nurse at the facility . medications were required upon the resident's arrival to the receiving facility. A physician order [REDACTED]. The MAR for (MONTH) 2019, revealed Lacosamide was not administered on 04/03/19, 04/06/19, 04/19/19 and 04/20/19 for the 8:00 AM dose, and on 04/13/19, 04/18/19 and 04/20/19 for the 8:00 PM dose. The MAR indicated [REDACTED]. The medical record lacked documented evidence the Attending Physician or the Nurse Practitioner was made aware R30 continued not to receive the Lacosamide [MEDICAL CONDITION] medication post hospitalization . On 04/24/19 at 3:26 PM, a Licensed Practical Nurse (LPN) explained if a resident was missing medications, the nurse would have called the pharmacy to inquire what was holding up the delivery of the medication. The nurse would have continued to follow-up the next day to see if the pharmacy sent the medication. The LPN indicated if the medication was still not available for the resident, the LPN would have informed the Director of Nursing (DON). The LPN indicated it was expected the DON would have contacted the Pharmacy Consultant to make sure the medication would have been available for the resident. The LPN indicated if a resident was not receiving medications for a period of time, the nurses were expected to inform the Physician. 04/25/19 at 3:38 PM, a Regional Pharmacist indicated the facility was expected to call the Pharmacist assigned to them for medications not received. On 04/26/19 at 8:31 AM, R30's Attending Physician indicated not recalling the DON or any of the nurses informed R30's [MEDICAL CONDITION] medications were not administered prior to the hospitalization and after R30's readmission to the facility. The Attending Physician indicated not being aware of any issues with the pharmacy for R30's medications. The Attending Physician indicated if the DON or the nurses had informed R30 had not been receiving the [MEDICAL CONDITION] medications, the Attending Physician would have ordered something else. On 04/26/19 at 2:25 PM, the Executive Director (ED) confirmed the Lacosamide was ordered 03/04/19 but was not delivered to the facility until 03/12/19. The ED indicated not knowing why the DON had not followed up with the pharmacy regarding timely delivery of this medication. The ED indicated being informed on 04/26/19 by the Pharmacy's Account Manager a valid prescription for the Lacosamide had not been received from the facility until 03/11/19. On 04/30/19 at 9:58 AM, the Medical Director revealed not being aware R30 had not received several [MEDICAL CONDITION] medications. The Medical Director (MD) indicated the DON did not bring the issue forward to the Executive Director. The MD indicated the DON did not inform the MD significant medications such as [MEDICAL CONDITION] and antibiotic medications were not being administered to the residents. The MD revealed the only issue which had been brought to the MD's attention was the difficulty of obtaining narcotic pain medications because of the need for physician scripts. The MD indicated not being made aware by the nursing staff R30 had been transferred to the acute hospital due to a [MEDICAL CONDITION] activity because R30 had not been receiving [MEDICAL CONDITION] medications consistently per physician orders. The MD acknowledged the nursing staff were responsible to provide an accurate report on R30 and made sure the hospital staff were aware of what has happened in the facility. The MD confirmed the DON or any nurse did not inform the MD R30 continued not to receive the Lacosamide after the resident was readmitted after the hospitalization . Resident #322 (R322) R322 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician order [REDACTED]. The Medication Administration Record [REDACTED]. The medication was not given because it was not delivered. A physician order [REDACTED]. The MAR for (MONTH) 2019, revealed R322 did not receive the [MEDICATION NAME] on 04/14/19 at 8:00 PM, 04/15/19 at 8:00 AM and on 04/20/19 at 9:00 AM. Progress notes dated 04/14/19 and 04/20/19, documented the [MEDICATION NAME] was not given due to medication not being available. A physician order [REDACTED]. The MAR for (MONTH) 2019, documented R322 did not receive the [MEDICATION NAME] on 04/14/19 at 6:00 AM and 2:00 PM. A Progress note dated 04/14/19, documented the [MEDICATION NAME] was not given due to not being available. On 04/25/19 at 3:38 PM, a Pharmacist indicated the facility was expected to contact their Pharmacist when medications were not received. On 04/26/19 at 8:31 AM, a Physician indicated they were not informed of significant medications not being administered to the residents. On 04/30/19 at 9:58 AM, the Medical Director indicated they were not aware of significant medications not being started on time as ordered. Resident #48 (R48) R48 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician order [REDACTED]. The Medication Administration Record [REDACTED]. The medical record lacked documented evidence of the physician being informed Lacosamide was not administered to R48 on several days. On 04/24/19 at 10:15 AM, the Licensed Practical Nurse (LPN) indicated the Physician would have been informed if a medication was not administered. The LPN indicated R48's Lacosamide was not administered on 04/23/19 since the medication was a controlled drug and required a prescription. The LPN acknowledged a documentation on physician notification should have been made for each missed dose of the Lacosamide. On 04/25/19 at 9:00 AM, the Registered Nurse indicated if a medication would not be administered on time due to a delivery or prescription issue, the Physician would be notified. On 04/26/19 at 9:15 AM, the Assistant Director of Nursing (ADON) indicated the nurses should have notified R48's physician when the medication was not available and documented in the medical record. The ADON confirmed the medication error should have been reported to R48's physician. The facility policy Administration of Medication dated 04/24/19, documented all medications would be administered safely and appropriately per physician order [REDACTED]. Medication Administration was the responsibility of the nursing professional.

Based on interview, record review, and document review, the facility failed to 1) ensure 2 of 8 sampled residents who required skilled nursing care and supervision were not inappropriately discharged to a residential facility for groups (Resident #2, #4); and 2) provide a safe discharge for 1 of 8 sampled residents discharged to her private home (Resident #8). Findings include: Resident #2 Resident #2 was admitted [DATE] and discharged [DATE]. Admission [DIAGNOSES REDACTED]. Resident #2 was discharged to Facility #1 on 6/29/12. Resident #2 had a gastrostomy tube ([DEVICE]), which required services and supervision by a skilled nurse. There was no documented evidence of a physician's discharge summary including Resident #2's medical condition and [DIAGNOSES REDACTED]. The Discharge Assessment Summary and Discharge Instructions form indicated the following: "Regular puree nectar thick liquids d/c'd (discontinued)." This sentence was crossed out and "NPO" (nothing by mouth) was written. "GT ([DEVICE]) [MEDICATION NAME] feeding three times / day". The Recapitulation of Stay indicated "Dietary Discharge Summary (signed and dated 6/27/12): Regular puree nectar thick liquids. Eats 50-100% meals wt (weight) 155# (pounds)." The Social Service Discharge Summary, which was signed by the Director of Social Services (not dated), indicated, "Alert and oriented. Cognitive skills are adequate. D/C: (Facility #1)." The section marked, "Nursing" was completely blank. The form further indicated, "Copy of instructions given to: (blank)." The same signatures were next to the signature line for the resident / person receiving instruction and for the licensed nurse. (It was verified by the DON (Director of Nursing) and the Administrator on the morning of 9/14/12 that this signature on the form dated 6/29/12 belonged to an admissions coordinator from Facility #1.) The following medications were listed on the discharge instructions: -Glucerna 6 cans per day per GT: Give 1 can every 4 (hours). -H20 (water) flushes 200 ml: 200 cc (cubic centimeters) of water every 6 (hours). -[MEDICATION NAME] 5 mg po: 1 tab (tablet) every Tues (Tuesday), Thurs (Thursday), Sat (Saturday), Sun (Sunday). -[MEDICATION NAME] 7.5 mg po: 1 tab every M-W-F (Monday - Wednesday - Friday). -Vit (vitamin) D 400 units: 1 tab 2x day -[MEDICATION NAME] 50 mg: 1 tab as needed for pain. -[MEDICATION NAME] 200 mg po: 1 tab in am. -[MEDICATION NAME] 10 mg: 1 tab at bedtime. -[MEDICATION NAME] 20 mg: 1 tab before breakfast. -[MEDICATION NAME] 25 mg: 1 tab 2x day -ASA (aspirin) 81 mg: 1 tab in AM. -[MEDICATION NAME] 10 mg: 1 tab in AM. -[MEDICATION NAME] 40 mg: 1 tab in PM. There were discrepancies in the discharge medication instructions and the (following) physician's orders [REDACTED]. The Physician's Telephone Orders indicated the following: 6/27/12 / 8:00 AM: "Option 1 to provide Glucerna for [MEDICATION NAME] feedings TID (3 times daily) via GT and to do family teachings. Provide GT feedings supply." 6/28/12 / 11:10 AM: "(Change) tube feeding to Glucerna 1.2 @ 70 ml / hr (hour) x 20 hrs = 1400 ml, 1680 kcals (calories), 84 gm (grams) protein, 1162 ml free H20 (water). H20 flush 200 ml q (each) 6 hr - total free H20 1962 mg / 24 hrs. 6/28/12 (no time indicated): "Dietary to (change) TF (tube feeding) to [MEDICATION NAME] feedings. Cont (continue) [MEDICATION NAME] 1.2 (secondary to) glucose intolerance. (change) TF to [MEDICATION NAME] feedings, [MEDICATION NAME], 6 cans per day per GT." (This telephone order was crossed out.) 6/28/12 (no time indicated): "Glucerna 6 cans per day per GT, D/C continuous feedings (secondary) to impaired glucose tolerance." The Nurse's Notes dated 6/29/12 at 2:30 PM indicated, "discharged to (Facility #1) @ 1330 (1:30 PM). D/C (with) meds (medications) and narcs (narcotics). On 9/14/12, Facility #1 provided a copy of their records for Resident #2. These records included a Discharge Assessment Summary and Discharge Instructions form which was signed by the Admissions Coordinator from Facility #1 and dated 6/29/12. The form was completely blank, with the exception of the "Activities Pursuits" section. Facility #1's records indicated Resident #2 was transferred to an acute care facility on 6/30/12 in the morning following a coughing incident that lasted approximately 10 to 15 minutes. Clinical records from the acute care facility (Facility #5) dated 6/30/12 indicated, "History of Present Illness: The patient is an [AGE] year old female...who had acute onset shortness of breath and cough at her home and was transported to the emergency department...In the emergency department, the patient was noted to be severely short of breath and was intubated for [MEDICAL CONDITION]: 1. Ventilator-dependent [MEDICAL CONDITION]. 2. status [REDACTED]. Findings consistent with clinical brain dead." On 9/13/12 in the afternoon, the Nurse Case Manager (Employee #5) indicated the responsibilities of a Nurse Case Manager were attending weekly meetings for residents who are ready to be discharged . She stated, "Aspiration precautions are to be up (in bed) before and after feeding, then check auscultation and residuals." The Nurse Case Manager verified there was no documentation that the RFG was informed of the need for aspiration precautions. The Nurse Case Manager indicated she normally starts the discharge form, "I prepare it and then I pass it on to the different departments. Then the nurse on the floor gives it to the family or person receiving the resident. Sometimes it's 2 or 3 days for the discharge form to be signed by everybody." Upon questioning, the Director of Social Services, the Nurse Case Manager (Employee #5), and the DON indicated that it was okay to discharge a resident with a [DEVICE] to an RFG. They verbalized they were not aware of the criteria for a safe discharge of a resident to an RFG. Resident #4 Resident #4 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #4 was discharged on [DATE] to Facility #1 (a non-medical residential facility for groups (RFG) / Assisted Living facility), which did not have an endorsement to provide care for persons with dementia. The history and physical examination History of Present Illness: The patient is an elderly woman with significant advanced Alzheimer dementia...She uses less than 6 words per minute, and usually does not talk, just stares. She is a high fall risk, having sustained a positive left [MEDICAL CONDITION] about 2 to 3 months ago, and unfortunately has not been able to walk since she did not do well with therapy because of her advanced dementia at this time with recurrent falls...The patient is fidgety and unable to be controlled, trying to get (out) of bed, and moving all over the place..." The Nurse's Notes dated 7/12/12 at 2:00 PM indicated, "Pt trying to get out of bed x 4, educated pt on safety, pt confused. Bed mat alarmed, initiated." The Discharge Assessment Summary and Discharge Instructions form dated 7/12/12 indicated, "...Alert and confused. Will be followed up by (Facility #4)...Recapitulation of Stay:..Social Service Discharge Summary: Discharging back to (Facility #1) (with) Hospice." There was no documented evidence in the discharge instructions form informing the receiving facility (Facility #1) of necessary fall risk precautions for Resident #4 (a demented resident with a history of a previous fall (with fracture), without safety awareness, and who had multiple attempts to get out of bed unassisted). The Discharge Assessment Summary Recapitulation of Stay had 4 sections (Dietary, Activity, Social Service, and Nursing), which were not signed and dated by any of the above department staff. The Nursing section was completely blank. Resident #8 Resident #8 was admitted [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. 9/10/12: "D/C (with) (Facility #3) to follow." 9/10/12: "D/C home tomorrow (with) meds / narcotics. D/C PICC (peripheral intravenous central catheter) line. F/U (follow up) (with) PCP (primary care physician)...Update pt on delivery of w/c (wheelchair) cushion, wedge pillow. Home Health Care for wound care if available." The Social Service Progress Notes indicated the following: 9/10/12: "Seen by (name of physician), new order for d/c home with (Facility #3) to follow pt to go home with meds and narcotics. D/C PICC line prior to discharge. F/U with pcp (primary care physician) to update wheel chair, wedge pillow. Home Health Care for wound care if available. Discharge Planner notified." 9/11/12: "Pt is to be d/c home tomorrow 9-12-12 at 6 am via stretcher with medic coach per (Employee #8) in the business office since pt lives in Pahrump and needs assistance to enter her house. Pt aware of situation, home health was offered to pt, pt refused since she has no insurance coverage. Pt is to be home with sister. MD (Medical Doctor) (name of physician) aware of situation." 9/12/2012: "Transferred home with belongings per w/c transport." 9/12/2012: "Pt was d/c home this am, via medical coach via stretcher, with (Facility #3) to f/u with pt today. Pt aware. 9/13/12: Nye County Sheriff's Office called (facility) soc ser (social services). Upon d/c the fire dept (department) and sheriff's dept were called to assist pt up her steps and in her house using their lift equipment..." On 10/3/12, the Assistant Administrator and the DON verified there was documentation in the chart (by the Rehabilitation Department, the Social Worker, and in the Weekly Care Meeting Notes) that Resident #8's private home had 3 steps in front of the front door. They further verified they were aware Resident #8 was obese (almost 350 pounds) and needed assistance with transfer and ambulation. The Assistant Administrator and the DON indicated a home assessment was not completed by the facility prior to the discharge. On 10/5/12 in the morning, the DON and the Nurse Case Manager (Employee #9) indicated they were not sure if a wheelchair and front wheel walker were provided to Resident #8 upon discharge. The DON verified there was no documentation of any durable medical equipment and specific medications were sent home with the resident. The Nurse Case Manager indicated she was newly hired at the time of Resident #8's discharge, and was not directly involved with the discharge arrangements. The Nurse Case Manager stated, "I did the home health part. I'm not sure who ordered the wheelchair and the other equipment." The Policies and Procedures included the following: "Transfers and Discharges" (Chapter 1 of the Social Services Manual, revised 6/17/08): "Policy: As members of the interdisciplinary team, Social Services staff participate in all room transfers and discharges, including room changes, transfers between facilities, and transfers between distinct parts within the same building. Transfers and discharges should be handled appropriately to ensure proper notification and assistance to residents and families in accordance with federal and state-specific regulations. Procedure: Transfers and discharges may occur:...When the resident's health has improved sufficiently so that he or she can return home or to a less restrictive environment..." "Discharge / Transfer of the Resident", revised 06/2010: "Purpose: *To provide safe departure from the facility. *To provide sufficient information for after care of the resident. Definitions: Discharge: to leave the facility without plans or intention to return (e.g., discharge to home, a lower level of care, or another long-term care facility)...Procedure: 6. Complete a discharge summary and post discharge plan of care form...b. Include restrictions for post discharge care and explain them to the resident and/or representative. c. Have resident and/or representative / person responsible for care sign discharge summary and post discharge care form..."