Every finding on record at Marquis Plaza Regency Post Acute Rehab

Based on interview, record review, and document review, the facility failed to ensure adequate supervision and appropriate post fall assessment following an unwitnessed fall of a resident identified as high risk for falls. The facility failed to recognize and respond in a timely manner to a significant change in condition, did not initiate required frequent and systematic neurological assessments, and did not ensure timely medical evaluation for 1 of 7 sampled residents (Resident 1). This deficient practice resulted in a delay in the identification and treatment of a serious head injury, as evidenced by findings of a left subdural hematoma (blood collecting between the brain and its covering on the left side) and subarachnoid hemorrhage (bleeding in the space around the brain), resulting in actual harm to the resident. Findings include:Resident 1 (R1) was admitted on [DATE], with diagnoses including cerebrovascular accident (CVA), intracranial hemorrhage (ICH), osteoarthritis, hypertension, and bilateral knee replacement.A Nursing Progress Note dated 11/20/2025, documented R1 was alert and oriented to person and place with periods of confusion. R1 had a history of dementia, cerebrovascular accident (CVA), intracerebral hemorrhage (ICH), osteoarthritis, congestive heart failure (CHF), hypertension, diabetes mellitus, and bilateral knee replacement. R1 was noted to have left knee swelling with limited range of motion.A Nursing admission assessment dated [DATE] documented R1 had a history of falls, including a fall within the month prior to admission, a fall within the previous 2-6 months, and a fracture related to a fall within the 6 months prior to admission.A Care Plan dated 11/21/2025 documented R1 was at risk for falls related to decreased mobility associated with infected knee hardware, pain requiring narcotic use, and a history of falls. R1 required assistance with mobility, including positioning, transfers, and ambulation, due to decreased mobility and weakness. Interventions included one person assistance and keeping commonly used items within easy reach.A Minimum Data Set, dated [DATE], documented the admission assessment reflected a Brief Interview for Mental Status score of 14, indicating R1's cognitive status was intact.Nursing Progress notes dated 12/12/2025 through 12/15/2025 documented R1's baseline mentation prior to the fall was alert and oriented to person, place, and time, pleasant, cooperative, and without neurological concerns.A Fall/Post Fall assessment dated [DATE], documented R1 was found on the floor in their room at 6:05 AM, lying on their back in a dark room, with the call light activated. R1 was unable to see where to go.The Situation, Background, Assessment, Recommendation (SBAR) dated 12/16/2025 at 4:09 PM, documented R1 received Oxycodone 10 mg, and was subsequently noted to be confused and disoriented, with continued confusion later in the evening. The physician was notified, and Oxycodone was discontinued, with a new order for Tramadol received.A Nursing Progress Note dated 12/17/2025 at 6:59 AM, the documented R1 was monitored overnight and continued to exhibit delirium and confusion.The SBAR dated 12/17/2025 at 1:00 PM, documented R1 was confused, lethargic, and forgetful following the fall on 12/16/2025, with decreased awareness of surroundings and refusal to eat. R1's family member requested transfer to the hospital, and the nurse practitioner approved the transfer for further evaluation.A Skilled Nursing Progress Note dated 12/17/2025 at 2:23 PM, documented R1 was alert but disoriented, lethargic, non-responsive at times, unable to hold conversation, and exhibited hallucination-like behaviors, with poor oral intake and decreased participation in therapy.On 04/13/2026 at 10:30 AM, a Registered Nurse (RN) assigned to the 100 hall, indicated upon admission, staff assessed fall risk by reviewing the residents' history and obtaining information from the residents or family, and implemented appropriate interventions. Following an unwitnessed fall, staff performed a body assessment, notified the physician and family, and followed physician orders. The RN indicated when signs of head injury were reported or observed, staff initiated neurological assessments and notified the physician for possible transfer for a head computed tomography (CT) scan.On 04/14/2026 at 2:10 PM, a night shift Registered Nurse (RN) recounted on 12/16/2025 at approximately 6:00 AM, they were preparing to administer R1's medications before the end of the shift. The RN reported R1's room door was closed, and upon entering, the room was dark, the call light indicator was activated, and the call light button was found on the floor. The RN recalled finding R1 on the floor lying on their back, slightly to the side, with their head positioned near the dresser, following an unwitnessed fall. The RN indicated R1 had likely attempted to ambulate to the bathroom without assistance and denied hitting their head. The RN reported R1's baseline was alert and oriented, with occasional forgetfulness, and that R1 required assistance with transfers and ambulation due to knee limitations. The RN indicated an SBAR and neurological assessment were not initiated at the time of the fall; however, a fall assessment was completed, and the nurse practitioner and family were notified. The RN confirmed R1 developed increased confusion, lethargy, and poor oral intake following the fall and was transferred to the hospital the next day at the family's request.On 04/14/2026 in the afternoon, a day shift Registered Nurse (RN) indicated they had received report regarding R1's unwitnessed fall on 12/16/2025 at 6:05 AM. The RN indicated, per report, R1 denied hitting their head and no neurological assessment was initiated; however, increased confusion and lethargy were later observed. The RN indicated the change in R1's condition was reported to the Nurse Practitioner (NP), and Oxycodone was changed to Tramadol. The RN indicated R1's condition continued to worsen on 12/17/2025 and indicated that, given R1's condition, more aggressive orders or interventions should have been considered.The RN confirmed the Nurse Practitioner (NP) evaluated R1 on 12/17/2025 in the morning, no CT scan was ordered, and laboratory tests were ordered for completion on 12/18/2025. The RN indicated the family visited on 12/17/2025 and requested a transfer due to R1's worsening condition. R1 was transferred to the hospital per family request.On 04/14/2026 at 4:35 PM, a Physician Assistant (PA) indicated the primary concern following a fall was resident safety. The PA indicated increased confusion and altered mental status following a fall represented a significant change in condition and constituted an emergency, particularly when the fall was unwitnessed. The PA indicated standard clinical practice required immediate evaluation, including ordering a STAT CT (An immediate Computed Tomography or head scan done without delay to check for brain injury or bleeding) without contrast to rule out intracranial injury.On 04/15/2026 at 10:30 AM, the NP indicated R1 had baseline periods of forgetfulness prior to the fall, with intermittent confusion noted during longer interactions, but was able to answer simple questions appropriately. The NP indicated following notification of the unwitnessed fall on 12/16/2025, the standard process included determining whether R1 hit their head and was on anticoagulants. The NP considered R1's confusion was attributed to multiple factors, including diagnoses and medication effects, and Oxycodone was changed to Tramadol. The NP indicated a STAT CT scan of the head was not ordered because R1 denied a head strike, was not on anticoagulants, and did not demonstrate findings during assessment that suggested intracranial injury.The NP indicated laboratory tests were ordered on 12/17/2025, for completion on 12/18/2025, and no immediate imaging or transfer was initiated based on assessment findings. The NP indicated there was no plan to transfer R1 to the hospital due to pending laboratory tests, and the plan was to await completion of the ordered tests and review of results prior to further intervention. The NP indicated transfer to the hospital occurred on 12/17/2025, after continued R1's confusion and lethargy per family request.The NP indicated in the case of an unwitnessed fall, it was unknown whether the resident sustained a head injury. The NP indicated staff were expected to initiate neurological assessments when a change in condition was present following an unwitnessed fall. The NP indicated neurological assessments differed from routine vital signs, as they required more frequent monitoring and a more in-depth evaluation of neurological status.The NP indicated if a resident struck their head and developed intracranial bleeding, it could result in neurological changes, including increased confusion and lethargy, and required prompt evaluation and intervention. The NP acknowledged that failure to address intracranial bleeding in a timely manner could lead to poor outcomes, depending on the severity and location of the bleed. The NP indicated potential outcomes could include significant harm or death if the condition was not promptly identified and treated.On 04/15/2026 at 2:50 PM, the Residential Care Manager (RCM) indicated facility protocol required initiation of a neuro assessment following an unwitnessed fall, consisting of every 15 minutes for the first hour, then hourly, and then every two hours thereafter. The RCM indicated neuro assessments were documented on a neuro assessment form separate from vital signs records. The RCM confirmed no neuro assessment was initiated or documented for R1 following the unwitnessed fall despite continued confusion.On 04/15/2026 in the afternoon, the Assistant Director of Nursing (ADON) indicated staff were expected to monitor R1 and report changes in condition following the unwitnessed fall on 12/16/2025. The ADON indicated increased confusion and lethargy were identified, but documentation did not reflect consistent neurological assessment. The ADON indicated neuro assessments were separate from routine vital signs and required specific documentation.On 04/15/2026 in the afternoon, a Physical Therapist Assistant (PTA) indicated familiarity with R1. The PTA indicated R1 required supervision for ambulation and was not safe to ambulate independently. The PTA indicated an unsupervised ambulation, especially in a dark environment increased the risk for falls.A hospital Transfer Summary dated 11/20/2025, documented a CT scan of the head revealed a chronic infarct with no evidence of acute intracranial bleeding.On 04/15/2026 at 10:50 AM, the NP confirmed R1's prior CT head findings reflected a chronic infarct, which represented a previous condition and not an active or acute process. The NP indicated that a chronic infarct did not represent active bleeding and confirmed there was no acute intracranial bleeding identified prior to the resident's admission to the facility. The NP indicated acute findings would represent new or recent changes and clarified the resident's prior imaging did not demonstrate any acute bleeding at the time of admission.On 04/15/2026 in the afternoon, the ADON confirmed R1's baseline CT prior to admission at the facility on 11/20/2025, documented as remarkable and showed no intracranial bleeding.The Nursing Progress Note dated 12/17/2025 at 4:56 PM, documented R1 was sent to the hospital. The facility Discharge summary dated [DATE] documented R1 sustained a fall on 12/16/2025 and denied head strike at the time. Following the fall, R1 exhibited increased confusion, lethargy, inability to hold conversation, and decreased oral intake. R1 remained disoriented, sleepy but arousable, and continued to demonstrate confusion. Per family request due to worsening conditions, R1 was transferred to the hospital on [DATE], for further evaluation.The Emergency Department records dated 12/17/2025 documented R1 presented from the facility following an unwitnessed fall on 12/16/2025, with subsequent confusion and altered mental status, and noted sudden worsening of mental status and bruising to the left cheek concerning for head strike; a CT scan of the head revealed a 4 mm left subdural hematoma (blood collection on the left side of the brain) and posterior left temporal subarachnoid hemorrhage (bleeding around the back-left part of the brain) with no significant mass effect (no pressure on the brain).A facility policy titled Managing Falls and Fall Risk dated 11/2022, indicated staff were required to monitor and document the resident's response following a fall and reassess and revise interventions when a fall occurred or condition changed.A facility policy titled Neurological Assessment - Level III (undated), indicated neurological assessments were to be performed upon physician order, following a fall involving head trauma, or with a change in condition. The policy indicated staff were to conduct frequent neurological checks and vital signs, monitor for lethargy, decreased level of consciousness, and weakness, and report any change in neurological status to the physician immediately.Complaint numbers 2742199 and 2730297

Based on observation, interview, record review and document review, the facility failed to ensure care orders were transcribed and carried out for a peripherally inserted central catheter (PICC) line for 2 of 40 sampled residents (Residents 159 and 164) and a short peripheral line was dated, and maintenance protocols were followed during non-use for 1 of 40 sampled residents (Resident 162). The deficient practice had the potential to place residents at risk of infection. Findings include: 1) Resident 159 (R159) was admitted on [DATE], with diagnoses including congestive heart failure and diabetes mellitus.On 09/09/2025 at 9:35 AM, R159 had single lumen intravenous (IV) access in the right upper arm with a dressing dated 08/29/2025. R159 indicated the PICC line was placed in the hospital for Insulin infusion to treat R159's diabetic ketoacidosis (a complication of diabetes resulting in elevated blood sugar and accumulation of ketones). R159 indicated the line was not used during the resident's first few days in the facility and almost became occluded but was successfully flushed by staff when the physician ordered IV Lasix (an anti-diuretic).On 09/09/2025 at 9:39 AM, a Registered Nurse (RN) confirmed R159 had a right upper arm PICC line which was dated 08/29/2025 and described black matter which appeared to be dried blood surrounding the insertion site. The RN explained the facility protocol was to replace PICC line dressings every seven days or as needed when soiled or loose. The RN indicated being floated to the unit and was new to the resident. The RN indicated that the nurses who have been administering IV Lasix should have identified the dressing was outdated and soiled and performed a dressing change. A Nursing admission assessment dated [DATE], revealed R159 was admitted with a right upper arm PICC line. The medical record lacked documented evidence maintenance orders for flushing, site assessment and dressing changes were entered on admission. A Physician Order dated 09/07/2025, documented to change PICC line dressing every seven days by night shift for maintenance. The Medication Administration Record (MAR) for September 2025, reflected PICC line dressing change had not been performed since R159's admission on [DATE].The medical record lacked documented evidence flushing and site assessment orders were transcribed and carried out in accordance with facility policy.A Physician Order dated 09/07/2025, documented to give Furosemide Injection Solution, use 20 milligrams (mg) intravenously two times a day for edema.2) Resident 164 (R164) was admitted [DATE], with diagnoses including cellulitis of left lower limb.On 09/09/2025 at 10:24 AM, R164 had a single lumen IV access in the left upper arm dated 08/17/2025. A white reinforcement tape was observed on the top and bottom edges of the transparent dressing. R164 explained the line was inserted in the hospital for antibiotics and had not been used at this facility since admission. R164 indicated staff did not routinely flush the line and no one had changed the IV dressing. On 09/09/2025 at 10:23 AM, the Resident Case Manager (RCM) indicated R164 had a left upper arm PICC line which was not in use. The RCM confirmed the dressing was dated 08/17/2025 and there was reinforcement tape on the top end and bottom end of the dressing. The RCM explained PICC line dressing changes were performed every seven days which was an overdue task for R164's PICC line. The RCM indicated that any nurse could have contacted a physician to determine whether the PICC line would be removed and if the physician ordered the PICC line to remain, maintenance orders to include flushing and site assessment every shift and weekly dressing change should have been entered and carried out.On 09/09/2025 at 10:32 AM, the RCM indicated staff did not follow maintenance protocols for R164's PICC line which placed the resident at risk for infection, occlusion and unnecessary reinsertion if a line was determined to be needed. A Nursing admission assessment dated [DATE], revealed R164 was admitted with a left antecubital (in front of the elbow) PICC line. A Physician Order dated 08/22/2025, documented IV PICC line dressing change by night shift every Sunday for IV maintenance and as needed if wet, soiled, dislodged or compromised.The medical record lacked documented evidence R164's PICC line dressing had been changed since admission. A Physician Order dated 08/22/2025, documented to administer Normal Saline flush solution 0.9 percent (%), use 10 milliliters (ml) intravenously every shift for clinical standard.Review of R164's medication administration record (MAR) revealed the PICC line was flushed on four shifts from 08/22/2025 to 09/09/2025.A Physician Order dated 08/24/2025, documented to remove the PICC line due to the resident not having IV medications.The MAR revealed a nurse signed off on R164's PICC line removal on 08/24/2025 which did not align with direct observation.On 09/10/2025 at 4:05 PM, the Director of Nursing (DON) indicated R159 and R164 were admitted with a PICC line in the absence of IV medication orders. The DON confirmed the medical record did not reflect the admitting nurse clarifying whether the residents' PICC lines were to be removed or maintained. If the physician ordered to keep the PICC line, maintenance orders to include flushing and site assessments every shift and weekly dressing change should have been transcribed and carried out. The DON explained that dressing changes were performed on Sundays by night shift staff, but the tasks were missed for R159 and R164 which placed the residents at risk of infection and line occlusion. The DON indicated the facility policy for midlines was provided because care and management of midlines were identical to care and management of PICC lines.The facility policy Midline Dressing Changes revised May 2017, documented the purpose of catheter dressing changes were to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. Documentation requirements included date and time dressing were changed, type of dressing placed, and signature of person who performed procedure. The facility policy Flushing Midline and Central Line IV Catheters dated May 2010, documented catheters were flushed at regular intervals to maintain patency and required a physician order. Documentation requirements included date and time of procedure, condition of IV site and notification of physician of any complications and signature of staff member who performed procedure. 3) Resident 162 (R162) was admitted on [DATE], with diagnoses including abnormality in blood chemistry and myopathy. On 09/09/2025 at 9:50 AM, R162 had an undated peripheral IV line in the left hand with plastic tape coming loose at the ends. R162 indicated the line was inserted for fluids to treat the resident's dehydration. An IV pump was stored by the resident's doorway. The resident verbalized the IV line had not been used since the nurse practitioner informed the resident lab results came back good.On 09/09/2025 at 10:00 AM, an RN confirmed R162's left-hand peripheral IV was inserted at the facility, and the dressing should have been signed and dated by the nurse who performed the insertion. The RN verbalized the line was no longer in use because the resident's dehydration had been resolved, and someone should have contacted the provider to obtain an order for removal since peripheral lines were meant for short term use. The RN described R162's IV line as covered with plastic tape which was coming loose at the edges.A Physician Order dated 09/03/2025, documented to insert hep lock (a short peripheral line typically flushed with Heparin instead of Saline) for IV infusion one time only for IV fluids.A Physician Order dated 09/03/2025, documented to give Sodium Chloride Solution 0.9 % at 75 ml per hour intravenously every shift for hydration for two days.The medical record lacked documented evidence an order for peripheral line removal was obtained or clarified with the provider after the fluids order was completed on 09/04/2025, and maintenance orders for flushing and site assessments were transcribed and carried out.On 09/10/2025 at 4:34 PM, the DON confirmed R162's fluids were started through a hep lock on 09/03/2025 for fluids times two days. The DON verbalized the laboratory results dated [DATE] revealed resolution of dehydration and a nurse could have obtained an order to remove the IV line.The facility policy titled The Insertion of a Peripheral Catheter revised August 2017, defined a peripheral short catheter was less than or equal to three inches in length and was not a steel-infusion set which was used for administration of IV fluids and/or medications. Once inserted, the label is affixed, which reflects the date and time of catheter insertion with initials. Documentation requirements include date and time of the procedure, type and length of catheter, location or site, signature and title of person who performed procedure. The facility policy titled The Removal of a Peripheral Catheter revised August 2017, documented a peripheral IV line was to be removed every 96 hours (4 days), immediately after suspected contamination, when rotating the site or when therapy was discontinued. Documentation requirements include date, time of procedure, reason for removal, any communication with the physician and any changes to treatment orders.

Based on observation, interview and document review, the facility failed to ensure fingernail care was provided for 1 of 40 sampled residents (Resident 147). The deficient practice had the potential for residents not to receive nail care.Findings include:Resident 146 (R146) was admitted on [DATE], with diagnoses including need for assistance for personal care and cognitive communication deficit.On 09/10/2025 at 9:45 AM, R146 was observed to have bilateral arms lying on the chest. The fingernails on both hands were approximately more than a quarter of an inch long with dark brown to black accumulations of dry substances embedded between the tip of the hand and nailbed. On 09/11/2025 at 9:30 AM, R146 was awake, conversive and just had finished eating breakfast. The resident was not sure why the fingernails were not trimmed. R146 indicated receiving showers from staff once to twice per week and no trimming of fingernails was provided.On 09/11/2025 at 10:34 AM, the Registered Nurse (RN) caring for R146 went to the bedside to inspect the fingernails and agreed the fingernails should have been trimmed. The RN indicated the certified nursing assistants (CNAs) should be inspecting and trimming fingernails during shower days. If a resident refused the care the assigned nurse should be informed.On 09/11/2025 at 12:35 PM, an RN indicated nurses and CNAs could trim a resident's fingernails. Nails should be assessed routinely during care, more so during shower days. Nailcare refusals from a resident should be communicated to nursing staff to be addressed accordingly.On 09/11/2025 at 2:00 PM, two Resident Care Managers (RCM) indicated finger and toenail assessments should be looked at during every care of a resident. The RCMs confirmed fingernails should be trimmed by the CNAs or nurses. Long fingernails could be an infection control concern as well as skin tears or scratches.The facility policy titled Assisting the Nurse in Examining and Assessing the Resident revised 08/2017, documented the procedure is to assist the nurse in gathering information about the overall condition of the resident and performance of activities of daily living. Grooming and Dressing: Assistance with bathing, hair and nailcare.

Based on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was developed and implemented for residents who were admitted with a peripherally inserted central catheter (PICC) line for 2 of 40 sample residents (Residents 159 and 164). The deficient practice had the potential to place the residents at risk of receiving inadequate PICC line care which could have resulted in complications such as infection and line occlusion. Findings include:1) Resident 159 (R159) was admitted on [DATE], with diagnoses including congestive heart failure and diabetes mellitus.On 09/09/2025 at 9:35 AM, R159 had a single lumen intravenous (IV) access in the right upper arm with dressing dated 08/29/2025. R159 indicated the PICC line was placed in the hospital for Insulin infusion to treat R159's diabetic ketoacidosis (a complication of diabetes resulting in elevated blood sugar and accumulation of ketones). R159 indicated the line was not used during the resident's first few days in the facility and almost became occluded but was successfully flushed by staff when the physician ordered IV Lasix (an anti-diuretic).On 09/09/2025 at 9:39 AM, a Registered Nurse (RN) confirmed R159 had a right upper arm PICC line which was dated 08/29/2025 and described black matter which appeared to be dried blood surrounding the insertion site. The RN explained the facility protocol was to replace the PICC line dressing every seven days or as needed when soiled or loose. The RN indicated being floated to the unit and was new to the resident. The RN indicated that the nurses who have been administering IV Lasix should have identified the dressing was outdated and soiled and performed a dressing change. A Nursing admission assessment dated [DATE], revealed R159 was admitted with a right upper arm PICC line. R159's baseline care plan initiated 09/03/2025, documented R159 had a PICC line with a goal to prevent complications and an intervention to follow physician order for dressing changes.The medical record lacked documented evidence that R159's dressing changes were followed in accordance with the care plan and failed to include other appropriate interventions such as flushing and site assessment. 2) Resident 164 (R164) was admitted [DATE], with diagnoses including cellulitis of left lower limb.On 09/09/2025 at 10:24 AM, R164 had a single lumen IV access in left upper arm dated 08/17/2025. A white reinforcement tape was observed on the top and bottom edges of the transparent dressing. R164 explained the line was inserted in the hospital for antibiotics and had not been used at this facility since admission. R164 indicated staff do not routinely flush the line and no one changed the dressing. On 09/09/2025 at 10:23 AM, the Resident Case Manager (RCM) indicated R164 had a left upper arm PICC line which was not in use. The RCM confirmed the dressing was dated 08/17/2025 and there was reinforcement tape on the top end and bottom end of the dressing. The RCM explained PICC line dressing changes were performed every seven days which was an overdue task for R164's PICC line. The RCM indicated that any nurse could have contacted a physician to determine whether the PICC line would be removed and if the physician ordered the PICC line to remain, maintenance orders to include flushing and site assessment every shift and weekly dressing change should have been entered and carried out.The medical record lacked documented evidence that the resident's PICC line was included in the baseline care plan. On 09/10/2025 at 4:26 PM, the Director of Nursing (DON) indicated R159's baseline care plan was not implemented specifically with regards to dressing changes and interventions were lacking flushing and site assessment protocols. The DON conveyed R164's baseline care plan failed to include care and management for the resident's PICC line which was an immediate care need.The Interdisciplinary Team Care Planning policy revised November 2017, documented care planning begins on the day of admission, and the baseline care plan was developed with the first 48 hours of admission and would include the resident's immediate care needs.

Based on interview, record review and document review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR- a federally mandated process which screens individuals seeking admission to a nursing facility (NF) to identify those with serious mental illnesses (SMI) or intellectual/developmental disabilities (ID/DD) to ensure individuals with these conditions receive the most appropriate placement) level II was completed for 1 of 40 sampled residents (Resident 155). The deficient practice had potential for not ensuring a resident with behavioral symptoms still fits within the resident population and for additional behavioral needs would be provided. Findings include: Resident 155 (R155) was admitted on [DATE], with diagnoses including bipolar disorder and hallucinations. Resident 155 was discharged on 05/12/2025.On 08/12/2025 at 11:00 AM, R155 was reported to have kicked a roommate twice on the lower leg and kicked the dietary person in the leg. R155 continued to exhibit behavioral issues as exhibited by trying to hit staff members and residents. R155 was transferred to a geriatric-psychiatric facility where the patient was admitted . Review of R155's nursing Behavior Complex Care Progress Notes from 03/09/2025 to 05/12/2025, revealed the following documented behaviors: Behaviors: Potential indicators of psychosis: Delusions - Resident stated people were trying to kidnap the resident. Resident believed that someone was trying to kill the resident. At one point the resident went back into the resident's room and blocked the door not allowing people to get into the room because the resident feared someone was trying to hurt the resident. The resident rummaged through the roommate's belongings and was found to be wearing the roommate's earrings which the resident claimed belonged to R155 and not the roommate. The resident claimed R155 owned the facility and could do whatever the resident wanted. The resident pulled the fire alarm when R155 did not get the attention the resident wanted.Physical behavior: Hitting others and kicking others. The resident kicked a roommate twice in the right lower leg and kicked the dietary person in the leg, The resident was hitting staff and other residents. Throwing objects at others. Grabbing others. Throwing the resident's shoe towards the certified nursing assistant (CNA) who attempted to stop the resident from harassing another resident. R155 hit the glass window at the day room with a folded walker. Splashed water at care providers.Verbal behavior: Cursing at others. R155 was frequently yelling, screaming, and cursing at staff, and other residents. The resident would scream inappropriate comments at others and use offensive foul language. R155 would ask repetitive questions/statements to disturb a roommate's rest after bedside care and stealing property of roommate like clothes, dress or any items the resident wanted to pick up. R155 would enter the roommate's persona space. Yelling and screaming on and off almost the entire shift. Behavior not exhibited toward others: R155 pulled the fire alarm one time. A nurse saw the resident trying to induce vomiting by inserting finger to throat. The resident claimed the resident was going on a car ride later and was worried about vomiting inside the car if the resident did not vomit now.Rejection of care: Medications were spit out. The resident would get upset when offered care. Resident had spit out the morning medications because the resident believed the medications could kill the resident. The resident refused a brief change from CNA. The resident purposely raised voice to get attention and disrupt others.Other behaviors: Behavior of disrupting others. The resident could be loud screaming especially at the nurse's station. R155 disrupts other residents' sleep during bedtime and disrupts staff while charting at the station. Multiple entries of behaviors were entered by nursing staff which demonstrates R155 was experiencing symptoms or indicators of significant mental illness.R155 had numerous documented routine Psychiatry Evaluations. The progress notes documented the following assessments: Initial Psychiatry Evaluation dated 05/30/2024 at 8:30AM, to the most recent Psychiatry visit dated 04/25/2025 at 11:15AM, consistently documented under Complexity/Medical Decision Making:1. Bipolar disorder with psychotic features - Continue Seroquel (anti-psychotic) 75 milligram (mg) three times a day (TID) to help address delusions associated with (a/w) bipolar disorder. Continue Fluoxetine (anti-depressant) 40 mg daily for depression a/w bipolar disorder.2. Generalized anxiety disorder - Continue Alprazolam (anti-anxiety) 0.5 mg TID for anxiety/restlessness. Continue Hydroxyzine 25 mg TID for restlessness.The Initial PASRR level I Screening form dated 07/05/2023, documented Determination: No mental illness, mental retardation, related condition or dementia. The PASRR deemed the resident was appropriate for nursing facility placement.R155 lacked documented evidence a PASRR level II assessment was completed even with R155 demonstrated behaviors of a serious mental illness (SMI) or the actual diagnosis from the psychiatric evaluations.On 09/11/2025 in the morning, two Registered Nurses (RNs) indicated behavioral incidents were documented on the progress notes. The RNs indicated the Resident Care Managers (RCM) would be informed of the behaviors as well. Any further directives would be received from the physicians or RCM.On 09/11/2025 at 2:14 PM, two RCMs indicated nurses would report any resident behaviors and would be discussed during interdisciplinary team (IDT) meetings. The RCM reviewed R155's EHR and confirmed the resident did not have a PASRR level II. On 09/11/2025 at 3:03 PM, a social worker (SW) confirmed the assigned SW to the specific resident attends the IDT meeting and would be informed of behavioral changes exhibited by a resident. The need for a Level II PASRR assessment would be determined at the IDT meeting. The SW acknowledged the purpose of the PASRR was to assess if the current facility was appropriate for the level of care or additional recommendations needed for a resident's behavioral needs. The SW acknowledged a level II PASRR was needed for R155. The facility policy titled PASRR Protocol - Nevada (Undated), documented when to complete the PASRR Level II Request: 1. When the resident is determined to have serios mental illness (SMI), mental retardation (MR) or related concerns (RC). 2. At any point if a person with SMI, MR or RC has an exacerbation of behaviors or indications of worsening mental health indicators.

Based on observation, interview, record review and document review, the facility failed to ensure the temperature in a resident's personal refrigerator was monitored for two unsampled residents (Residents 63 and 94). The deficient practice had the potential for foods to be stored at temperatures which could lead to food borne illness.Findings include: Resident's (R63) was admitted on [DATE], with diagnoses including hyperlipidemia, atherosclerotic health disease and heart Failure.Resident's R94 was admitted on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, hyperlipidemia, and gastro-esophageal reflux disease.On 09/09/2025 at 9:30 AM, the two unsampled resident's personal refrigerator contained undated food items and there was no temperature log.On 09/12/2025 at 10:00 AM, R63 mentioned family members regularly checked the refrigerator and disposed of any expired food. R63 checked the dates on the food to make sure it was not expired. R63 stated family members helped by checking the temperature of the refrigerator.On 09/12/2025 at 10:06 AM, R94 checked the expiration dates on food items and discarded anything expired. R94 had asked the housekeeper to clean out the refrigerator and throw away any expired food. R94 explained that the housekeeper checked the refrigerator temperature.On 09/12/2025 at 10:20 AM, a housekeeper explained the inside of residents' personal refrigerators were cleaned upon resident request, and expired food were thrown away at those times. The housekeeper explained the outside of the refrigerator was cleaned regularly during routine room cleaning.On 09/12/2025 at 10:35 AM, a maintenance staff member indicated monitored the temperatures of the facility refrigerators, not resident's personal refrigerator. The maintenance staff member verbalized checking a personal refrigerator if a Certified Nursing Assistance (CNA) or nurses reported an issue, such as a water leak, or if a resident reported the refrigerator was working properly.On 09/12/2025 at 10:45 AM, CNA1shared personal refrigerators were checked daily for leftover or expired food, but not for temperature.On 09/12/2025 at 10:56 AM, CNA2 checked the resident's refrigerator to see if it was clean or not. If a resident informed the CNA the freezer was too icy, the CNA would adjust the temperature. The CNA did not take the actual temperature.On 09/12/2025 at 11:57 AM, the Director of Nursing (DON) explained CNAs were responsible for checking residents' personal refrigerators daily and discarding any expired food. The DON noted within the medical task documentation system, CNAs could mark yes or no to indicate whether the temperature was checked. There was no recorded temperature log available. The DON checked the temperature of R94 and R63 personal refrigerator, which read 50 degrees Fahrenheit. The DON acknowledged the refrigerators for R94 and R63 were too warm and needed to be cooler than 40 degrees Fahrenheit. The DON indicated when family members bring in food which did not have a manufacturer's expiration date, it must be labeled with a date. The DON mentioned that the resident's food was permitted to remain in the refrigerator for up to 72 hours (3 days) before CNAs were required to discard it.The DON confirmed a temperature log should be maintained for personal refrigerators but was unable to provide any documented temperature log for residents R94 and R63 personal refrigeratorsThe facility policy titled Resident/Patient Food from Outside Sources, effective 4/2018 documented designated staff would monitor resident's room and refrigeration units for food and beverage disposal. Any unlabeled, expired or undated food would be discarded. Food items without a manufacturer's expiration date would be discarded after 3 days. Refrigerator and freezers temperature would be recorded daily on a temperature log. All units must maintain safe internal temperatures in accordance with the state and federal standards for safe food storage temperatures.

Based on observation, interview, record review and document review the facility failed to ensure physician orders with therapy settings were obtained and a comprehensive care plan developed for 1 of 40 sampled residents (R172) receiving Continuous Positive Airway Pressure (CPAP- a medical device used to help people breathe more easily during sleep) treatment. The deficient practice had the potential to result in inappropriate or ineffective treatment for residents receiving CPAP therapy. Findings include:Resident 172 (R172) was admitted to the facility on [DATE] with diagnoses including displaced comminuted fracture of shaft of right femur, type 2 diabetes mellitus, and gastro-esophageal reflux disease.A Physician Order dated 08/28/2025 documented to use CPAP every night.R172's medical record lacked a care plan for CPAP use. On 09/11/2025 at 11:29 AM, a Registered Nurse (RN) explained the Respiratory Therapist (RT) managed CPAPs for the residents. On 09/11/2025 at 11:31 AM, the RT Director explained the RT department was responsible for equipment changes and the initial setup of CPAP equipment for residents.On 09/11/2025 at 11:38 AM, the RT Director explained being unaware R172 had a CPAP. The RT Director explained that if a resident brought a CPAP device from home the settings would have been preset in the device, and the physician order would denote the settings needed. On 09/12/2025 at 9:00 AM, the Resident Care Manger (RCM) explained when a resident required the use of a CPAP the RCM would coordinate with RT services to establish setup of the equipment. The RCM explained residents using CPAP would have a care plan developed by the case manager. On 09/12/2025 at 10:17 AM, the RCM verbalized R172 was not admitted to the facility with orders for CPAP. The family brought the CPAP machine to the facility after the resident was admitted . The RCM verbalized R172's physician order was entered by the charge nurse when the family delivered the device on 08/28/2025. The RCM confirmed that R172 lacked a care plan for the use of CPAP.On 09/12/2025 at 10:21 AM, the Director of Nursing (DON), explained the expectation for a resident using CPAP therapy would be for the physician order to include the specific settings required for use and for the resident to have a care plan in place for the use of the device. The DON confirmed R172's physician order lacked the specific settings required for use of the CPAP and R172's medical record lacked a care plan for use of the CPAP. The facility policy titled CPAP/BiPAP (bilevel positive airway pressure) Support- Level III, revised 06/2018, documented review the physician orders to determine the oxygen concentration and flow, and the PEEP (positive end-expiratory pressure) pressure for the machine and set CPAP settings on the machine, as prescribed. The facility policy titled Care Plans- Person Centered Comprehensive, revised 10/2024, documented assessments of residents were ongoing, and care plans are revised as information about the resident and the resident's condition change.

Based on observation, interview, record review, and document review, the facility failed to notify the resident representative of an incident, and a skin tear identified for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to deprive the resident's representative the right to be informed of changes to the resident's health status. Findings include: Resident 1 (R1) R1 was admitted [DATE], with diagnosis including encounter for attention to gastrostomy, urinary tract infection, and pneumonitis due to inhalation of food and vomit. An Admissions Social Services document effective date 01/03/2025, documented R1's cognitive status was confused. A Brief Interview for Mental Status Assessment (BIMS) was unable to be conducted due to communication deficits. R1 was difficult to be understood and at times responses, when understood, were inconsistent with the questions. A Care Plan initiated 01/13/2025, documented R1 had cognitive deficit characterized by deficit in memory, judgment, decision making and though process related to Transient Ischemic Attack, short term memory loss. An Admissions Record dated 01/02/2025, listed a family member as R1's representative and emergency contact, along with a phone number provided. A Behavior Note dated 01/24/2025 at 1:18 AM, documented R1 was confused, anxious, agitated, combative, and tried to get out of bed multiple times. R1 was redirected and did not comply. In order to provide a safety environment, R1 was transferred to a wheelchair and moved nearby to the nurse's station. During transfer R1 started kicking and swinging, acquired an open area on R1's left lower leg, and a dressing was applied. A Skin and Wound Evaluation dated 01/24/2025 at 5:27 PM, documented a new skin tear on R1's front, left lateral, lower leg, in-house acquired. A Physician's Assistant was notified. The Skin and Wound Evaluation lacked documented evidence R1's representative was notified of the newly identified skin tear. R1's medical record lacked documented evidence R1's representative was notified of the incident and skin tear that took place on 01/24/2025. On 05/06/2027 at 9:42 AM, the Resident Case Manager, reported R1's family was very active and hands on with R1's care. On 05/06/2027 at 1:13 PM, the Resident Case Manager, confirmed the medical record lacked documented evidence the resident's family was notified of the incident and skin tear acquired. The Resident Case Manager acknowledged the family should have been notified of the incident and skin tear, especially because the resident was incoherent. On 05/06/2027 at 1:41 PM, the Administrator confirmed R1's medical record lacked documented evidence the family was notified of the incident and skin tear. The Administrator acknowledged the family should have been notified of the incident and skin tear. The Administrator explained since the incident happened late at night, the family should have been notified by the following morning. A facility policy titled Change in a Resident's Condition or Status revised 08/01/2021, documented the facility shall notify the resident, his or her Attending Physician/Medical Professional, and resident representative of changes in the resident's medical/mental condition and/or status. The Nurse should notify the resident's representative including when the resident was involved in any accident or incident that resulted in an injury, including injuries of an unknown source, and if there was a significant change in the resident's physical, mental, or psychosocial status. Complaint NV00073412

Based on interview, clinical record review, and document review, the facility failed to ensure 1 of 5 residents reviewed for vaccinations, including pneumococcal vaccines (Residents #66) was screened for eligibility to receive a pneumococcal vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the indicated pneumococcal vaccine was offered and either administered or declined. The deficient practice may have placed the resident at risk for not being protected against serious illness. Findings include: Resident #66 Resident #66 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including iron deficiency anemia, shortness of breath, chronic obstructive pulmonary disease, and unspecified asthma. Resident #66's clinical record lacked documented evidence the resident was screened for eligibility to receive a pneumococcal vaccine, and education regarding the vaccine was provided to the resident and/or the resident representative, and the indicated pneumococcal vaccine was offered and either administered or declined. On 09/20/2024 at 2:00 PM, the Infection Preventionist confirmed the facility lacked documented evidence Resident #66 was screened for eligibility to receive a pneumococcal vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the indicated pneumococcal vaccine was offered and either administered or declined. The facility policy titled Pneumococcal Vaccine, dated 10/20/2020, documented all residents were offered pneumococcal vaccines to aid in the prevention of pneumococcal infections. Prior to or upon admission residents were assessed for eligibility to receive a pneumococcal vaccine, and when indicate the vaccine was offered within 30 days of admission. A review of prior vaccination status was conducted within five working days of the resident's admission. The resident or legal representative received information and education regarding the risk and benefits of receiving the vaccine. Residents or the resident's legal representative had the right to refuse vaccination. The date of vaccination, lot number expiration date, name of the person administering the vaccine, and the site of the vaccination were documented in the resident's clinical record. Administration of the pneumococcal vaccine was made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on clinical record review, document review, and interview, the facility failed to ensure licensed staff did not jeopardize a resident's hemodialysis catheter for 1 of 29 sampled residents (Resident #57). This deficient practice may have placed the patient at risk for delays in dialysis treatments, unnecessary discomfort and medical/surgical interventions. Findings include: Resident #57 (R57) R57 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic kidney disease, stage 5, end stage renal disease, dependence on renal dialysis, and hyperkalemia. R57's Care Plan initiated on 06/18/2024, documented no intravenous therapy, blood draws, or blood pressure to left arm. A physician's order dated 06/17/2024, documented no blood pressure on left arm, every shift. A review of R57's vitals documented blood pressures were taken on the left arm on the following dates and times: - 08/28/2024 at 10:54 AM, 139/73 mmHg, sitting left arm - 08/27/2024 at 8:27 PM, 142/78 mmHg, sitting left arm - 08/27/2024 at 9:32 AM, 154/74 mmHg, sitting left arm - 08/26/2024 at 7:33 PM, 122/64 mmHg, lying left arm - 08/25/2024 at 7:54 PM, 126/64 mmHg, lying left arm - 08/25/2024 at 10:43 AM, 124/62 mmHg, sitting left arm - 08/22/2024 at 8:47 PM, 135/70 mmHg, sitting left arm - 08/22/2024 at 10:24 AM, 124/50 mmHg, sitting left arm - 08/21/2024 at 7:51 PM, 153/80 mmHg, sitting left arm - 08/21/2024 at 10:32 AM, 138/64 mmHg, sitting left arm - 08/19/2024 at 8:12 PM, 110/60 mmHg, lying left arm - 08/18/2024 at 9:01 PM, 118/70 mmHg, sitting left arm - 08/17/2024 at 7:03 PM, 128/64 mmHg. lying left arm - 08/17/2024 at 11:41 AM, 124/60 mmHg, lying left arm - 08/15/2024 at 9:48 PM, 128/60 mmHg, sitting left arm - 08/14/2024 at 9:11 PM, 103/60 mmHg, sitting left arm - 08/12/2024 at 7:29 PM, 122/64 mmHg, lying left arm - 08/12/2024 at 4:00 PM, 118/62 mmHg, lying left arm - 08/08/2024 at 8:32 PM, 130/65 mmHg, sitting left arm - 08/08/2024 at 10:09 AM, 118/64 mmHg, sitting left arm - 08/07/2024 at 8:02 PM, 105/60 mmHg, sitting left arm - 08/07/2024 at 10:46 AM, 146/74 mmHg, sitting left arm - 08/05/2024 at 8:44 PM, 100/49 mmHg, sitting left arm - 08/04/2024 at 9:34 AM, 130/70 mmHg, lying left arm - 08/01/2024 at 8:48 PM, 135/60 mmHg, sitting left arm - 08/01/2024 at 8:48 AM, 118/65 mmHg, sitting left arm An Outpatient Dialysis Record dated 09/09/2024, documented R57's left upper arm graft was clotted and dialysis was not performed. R57 was referred to a surgery center. A Surgery Center Note dated 09/10/2024, documented R57 had a fistulagram due to a 50% stenosis in the arterial graft segment and a 50% in-stent stenosis in the venous graft segment. The stenosis was treated with angioplasty and hemostasis was achieved. A Surgery Center Note dated 09/19/2024, documented R57 had a fistulagram which demonstrated a 70% stenosis in the venous graft and an 80% stenosis in the axillary vein. The stenosis was treated with angioplasty and hemostasis was achieved. On 09/20/2024 at 8:55 AM, a Licensed Practical Nurse (LPN1), verbalized the resident was getting hemodialysis and had a left upper arm fistula. LPN1 verbalized R57 had a procedure done yesterday due to a previous thrombosis. LPN1 verbalized there was an order to not take blood pressures on the resident's left arm, the arm of the fistula. LPN1 confirmed the resident's clinical record included documented evidence of previous blood pressures taken on the resident's left arm. LPN1 verbalized taking blood pressures on arm with the fistula can ruin the fistula, dislodge it, put resident in to stress. On 09/20/2024 at 9:44 AM, a Licensed Practical Nurse (LPN2), confirmed the resident's clinical record included documented evidence of previous blood pressures taken on the resident's left arm. LPN2 confirmed R57 had a left upper arm fistula. LPN2 confirmed R57 had a physician's order dated 06/17/2024, documented to not take blood pressure on the left arm. LPN2 verbalized taking a blood pressure on the resident's left upper arm could burst out the fistula and damage the port. On 09/20/2024 at 9:51 AM, the Director of Nursing (DON), confirmed R57 had a fistula on the left upper arm. The DON verbalized standard of practice was to not take a blood pressure on the arm with a fistula. The DON verbalized it would put pressure on fistula could cause bleeding and the port to clot. The DON confirmed the physician's order, dated 06/17/2024, to not take left arm blood pressures. The DON confirmed R57's clinical record documented multiple blood pressures taken on the resident's left arm. The DON confirmed R57 had a thrombosis in fistula on 09/09/2024, and dialysis was not done as scheduled on 09/09/2024. The DON verbalized a surgical procedure was done 09/10/2024 to remove the thrombosis. The DON verbalized a sign was at the head of the resident's bed indicating no blood pressures to the left arm. On 09/20/24 at 10:03 AM, a sign was observed at the head of the resident's bed documenting no IV, blood draws or blood pressure to left arm. On 09/20/24 at 10:45 AM, a Registered Nurse (RN) from the resident's Dialysis Center verbalized staff should never take a blood pressure on the arm of a resident's fistula. The RN verbalized it can collapse the fistula access and produce a clot. The facility policy titled End-Stage Renal Disease, Care of Resident with Dialysis, revised 08/2017, documented residents with end stage renal disease will be cared for according to currently recognized standards of care. Education and training of staff included the care of shunts and fistulas.

Based on observation, interview, clinical record review, and document review the facility failed to ensure medication was administered with an error rate less than 5 percent (%). There were 27 opportunities and 7 medication errors. The medication error rate was 25.93%. Findings include: Resident #82 (R82) R82 was admitted to the facility on [DATE], with diagnoses including cerebrovascular disease, unspecified, essential hypertension, and hyperlipidemia. An Order Summary for R82 documented the following: -Aspirin EC tablet Delayed Release 81 milligrams (mg), give one tablet by mouth one time a day related to essential hypertension. -Lisinopril tablet 40 mg, give one tablet by mouth one time a day related to essential hypertension. -Protein Gel/Liquid, one time a day, give 30 milliliters (ml) protein liquid in 120 ml juice. -Cholecalciferol tablet 1000 unit, give 2000 units by mouth one time a day for supplement. -Plavix 75 mg (Clopidogrel Bisulfate), give one tablet by mouth one time a day related to cerebrovascular disease, unspecified. -PreserVision AREDS 2+ Multivitamin oral capsule, give two capsules by mouth one time a day for supplement. -Vitamin C tablet 500 mg (Ascorbic Acid), give one tablet by mouth in the morning for supplement. On 09/19/2024 at 9:13 AM, a Licensed Practical Nurse (LPN) administered the following medications to R82: -Aspirin EC tablet Delayed Release 81mg, one tablet by mouth -Lisinopril 40 mg, one tablet by mouth -Protein Gel/Liquid 30 ml, 30 ml by mouth in 120 ml juice -Cholecalciferol 1000 units, two capsules by mouth -Plavix 75 mg, one tablet by mouth -PreserVision AREDS 2+ Multivitamin oral capsule, two capsules by mouth -Vitamin C 500 mg, one capsule by mouth On 09/19/2024 at 9:17 AM, the LPN explained a daily medication was to be administered at 8:00 AM, and could be administered one hour before or one hour after 8:00 AM. The LPN confirmed R82 was administered seven medications late and not according to policy. On 09/20 2024 at 2:28 PM, the Director of Nursing (DON) explained the expectation of licensed nursing staff was to administer all medications using the five rights of administering medications: right patient, right time, right dose, right medication, and right route. The DON confirmed medication administration occurring after 9:00 AM was considered a late medication administration and did not follow policy. The facility policy titled Administering Medications, revised 08/2017, documented medications would be administered in accordance with the orders, including any required timeframe. After verifying the right resident, the individual administering the medication must check the label three times to verify the right medication, the right dosage, the right time, and the right method of administration before giving the medication. Medications would be administered in a safe and timely manner, and as prescribed.

Based on observation, clinical record review, interview, and document review the facility failed to ensure a wound care nurse followed physician orders for 1 of 29 sampled residents (Resident #61). The deficient practice had the potential to place the resident at risk for delayed healing of a wound. Resident #61 Resident #61 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. A Skin Wound Assessment form dated 09/18/2024, documented Resident #61 had a facility acquired unstageable pressure injury (PI) to the front of the resident's right knee. The wound measured 0.9 cm area, 1.2 cm length x 1.1 cm width. The PI was documented as healing slowly or stalled but stable. A physician's order dated 05/21/2024, documented to cleanse the unstageable wound to Resident #61's right knee with normal saline, pat dry, apply barrier cream and then cover with foam dressing, three times per week and as needed for soiling and/or accidental removal. On 09/19/2024 at 9:46 AM, during a wound care observation, the Wound Care Nurse gathered supplies to perform wound to a wound on Resident #61's right knee. The supplies included silver alginate. On 09/19/2024 at 9:50 AM, during the provision of wound care for Resident #61, the Wound Care Nurse applied Tri-Ad cream to a silver alginate pad and placed the dressing over the wound on Resident #61's right knee, and dressed with island gauze. The Wound Care Nurse confirmed an order for silver alginate should have been obtained prior to use. On 09/19/2024 at 9:58 AM, the Wound Care Nurse verbalized had been using silver alginate on Resident #61's right knee wound for approximately one week. The Wound Care Nurse confirmed Resident #61's clinical record lacked an order for the use of silver alginate and an order for silver alginate should have been obtained and entered into the resident's clinical record prior to use. On 09/19/2024 at 10:58 AM, the Director of Nursing Services (DNS) confirmed a physician's order was required for wound care. The DNS explained wounds were assessed weekly to determine the effectiveness of the treatment being provided, and if after two weeks the wound was not improving, a new order was requested. On 09/19/2024 at 11:04 AM, the DNS confirmed a wound care assessment dated [DATE], documented the physician was notified Resident #61's PI wound was not improving. The DNS confirmed Resident #61's clinical record lacked documented evidence of a physician's order for the use of silver alginate when providing wound care to the PI on Resident #61's right knee. The DNS confirmed a physician's order was required prior to the use of silver alginate. A facility policy titled Wound Care -Level II, revised 03/2017, documented the first step when preparing to provide wound care was to verify there was a physician's order in place. A facility policy titled Physician Medication Orders, documented medication and treatments were administered only upon the order of a person duly licensed to prescribe such medications. Physician orders for medications and treatments were to be documented in the clinical record as provided per order.

Based on clinical record review, interview, and document review, the facility failed to ensure Comprehensive Care Plans included a care plan related to 1) the care and treatment for constipation (Resident #24), 2) the care and treatment of insomnia and constipation (Resident #134), 3) the care and treatment of edema (Resident # 134), and 4) the care and treatment of post-traumatic stress disorder (PTSD) (Resident #28) to include goals, preferences, needs, and interventions, for 4 of 29 sampled residents. The deficient practices had the potential to deprive residents of necessary care and treatments. Findings include: Resident #24 (R24) R24 was admitted to the facility 09/09/2024, with diagnoses including pain in left hip, presence of left artificial hip, and acquired absence of right leg below knee. On 09/18/2024 at 9:45 AM, R24 verbalized had been constipated and needed more than the stool softeners prescribed. The resident explained had received a suppository on 09/17/2024, and the suppository gave some relief. On 09/19/2024 at 8:32 AM, a Certified Nursing Assistant verbalized R24 had complaints of constipation. On 09/19/2024 at 2:23 PM, a Registered Nurse (RN) verbalized R24 took pain medication for chronic pain and the pain medications could cause constipation. The RN explained the resident received a scheduled stool softener twice a day for constipation and had as needed medications for bowel care as well. The resident received Miralax on 09/16/2024, and a Dulcolax suppository on 09/17/2024, which yielded a bowel movement. A physician's order dated 09/09/2024, documented Colace oral capsule 100 milligram (mg). Give one capsule by mouth two times a day for constipation. A physician's order dated 09/09/2024, documented Senna tablet 8.6 mg. Give two tablets by mouth as needed for bowel care/no bowel movement. A physician's order dated 09/09/2024, documented Miralax Powder (Polyethylene Glycol 3350). Give 17 grams by mouth as needed for bowel care. Give in 4-8oz water/fluid as needed if no bowel movement. A physician's order dated 09/09/2024, documented Dulcolax suppository 10 mg. Insert one suppository rectally as needed for bowel care/no bowel movement, if Miralax or Senna not effective within 24 hours. R24's Comprehensive Care Plan lacked a care plan for constipation. On 09/20/2024 at 2:44 PM, the Director of Nursing (DON) verbalized R24 received pain medications and medications to prevent constipation as a result of the pain medications. The DON confirmed R24 did not have a care plan for constipation and should have. Resident #134 (R134) R134 was admitted to the facility on [DATE], with diagnoses including nondisplaced intertrochanteric fracture of left femur, subsequent encounter for fracture with routine healing and nontraumatic hematoma of soft tissue. On 09/19/2024 at 2:23 PM, an RN verbalized R134 received Melatonin for insomnia and Lasix for edema. The RN explained the staff looked for pitting and swelling and would expect to find a care plan for edema and insomnia on the resident's care plan. A physician's order dated 09/05/2024, documented Melatonin 5 mg tablet. Give one tablet by mouth one time a day for insomnia. A physician's order dated 09/11/2024, documented Lasix 40 mg tablet. Give one tablet by mouth two times a day for edema in the lower extremities. R134's Comprehensive Care Plan lacked a care plan for insomnia and edema. On 09/20/2024 at 2:35 PM, the DON verbalized the expectation was a care plan would be created for a resident with insomnia and edema. The DON confirmed R134 took medications for insomnia and edema and should have had a corresponding care plan. 43311 Resident #28 Resident #28 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder, chronic, and metabolic syndrome. The Minimum Data Set 3.0 (MDS) Report, Section I, I6100:Post Traumatic Stress Disorder, documented Resident #28 had a diagnosis of PTSD. Resident #28's physician order dated 02/01/2024, documented Prazosin HCL oral capsule 2 milligrams, give one capsule by mouth as needed for history related to PTSD, chronic. A behavior note dated 09/12/2024, documented Resident #28 became upset when the facility transport did not show up to transport the resident to an eye doctor appointment. Resident #28 became angry and drove down the sidewalk and away from the facility with staff following. Resident #28 was redirected back to the facility with staff and was informed the eye appointment had been rescheduled to another day. Resident #28's clinical record lacked documented evidence the care plan included care for the resident's diagnosis of PTSD. On 09/19/2024 at 4:13 PM, a Resident Care Manager (RCM) explained a care plan was created for PTSD to include behaviors specific to the resident like aggressiveness or depression, and would include what alleviated those behaviors. On 09/19/2024 at 4:38 PM, the RCM confirmed Resident #28 did not have a care plan created or implemented to address the resident's chronic PTSD. On 09/20/2024 at 11:22 AM, the Assistant Director of Nursing (ADON) explained a resident with a history of PTSD, behaviors, and taking medication for PTSD should be care planned. The ADON confirmed Resident #28 was not care planned for the focus, goals, and interventions of PTSD. The facility policy titled Care Planning-Interdisciplinary Team, dated 11/2017, documented the care plan was recognized as an interdisciplinary dynamic process that included at a minimum: nursing, social services, activities, and dietary. The care planning process began on the day of the admission by nursing and the Interdisciplinary Team was responsible for the development of an individualized comprehensive care plan for each resident on an ongoing basis. The facility policy titled Goals and Objectives, Care Plans, dated 11/2017, documented care plans would incorporate Person-Centered goals and objectives that lead to the resident's desired outcome. The facility policy titled Care Plans-Person Centered Comprehensive, dated 08/2017, documented an individualized Person-Centered comprehensive care plan included objectives and goals to meet the resident's medical, nursing, mental, and psychological needs and was developed for each resident based on the resident strengths, needs, and preferences.

Based on clinical record review, document review, and interview, the facility failed to complete a discharge summary by the primary care provider to include the recapitulation of the resident's stay and the treatment and services obtained at the facility for 1 of 2 sampled closed records (Resident #142). The deficient practice has the potential to impact the resident not receiving the appropriate post discharge care, medications or treatments. Findings include: Resident #142 (R142) R142 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential (primary) hypertension, type 2 diabetes mellitus with diabetic neuropathy, and fibromyalgia. The resident was discharged on ,d+[DATE]. R142's Discharge Summary lacked evidence of a physician's signature, diagnoses, recapitulation of the admission to include the course of treatment and services provided by the facility. A Nursing Note dated 02/19/2024 at 11:12 AM, documented the physician was notified R142 would like to be discharged from the facility 02/19/2024. R142's daughter was able to get the resident an apartment. The resident had a private physician and pharmacy in the community. Nursing gave diabetes mellitus insulin education and would leave with all of the resident's medications on hand at the facility. The facility received a physician's order for the resident to be discharged from facility on 02/19/2024. A Discharge Note dated 02/19/2024 at 1:32 PM, documented R142 for discharge home on 02/19/2024. Refresher training for insulin check and insulin administration was done with the resident doing the procedure. The resident verbalized the resident knew how to do it and had done it before. Medications on hand were given to the resident. R142 left the facility at 1:25 PM ambulatory with front wheeled walker accompanied by family member in stable condition. On 09/20/2024 at 2:25 PM, the Social Services Director verbalized the facility lacked documented evidence of a complete Discharge Summary. On 09/20/2024 at 3:05 PM, the Medical Records Clerk confirmed Resident #142's clinical record lacked documented evidence of a complete Discharge Summary. On 09/20/2024 at 3:05 PM, the Medical Records Director confirmed Resident #142's clinical record lacked documented evidence of a complete Discharge Summary by the primary care provider to include the recapitulation of the resident's stay and the treatment and services obtained at the facility. On 09/20/2024 at 3:54 PM, the Administrator verbalized the wrong template was used for R142's discharge, the facility did not have a Discharge Summary, and the resident was not provided a recap of the resident's admission or an explanation of the course of treatments and services provided at the time of discharge. The Administrator confirmed the family or resident's representative was also not given the documentation regarding the resident's admission.

Based on observation, interview, record review and document review, the facility failed to ensure a care plan was accurately developed in accordance with the resident's assessment for 1 of 27 residents (Resident 124). Specifically, the resident's assessment reflected the resident required extensive assistance by two persons for bed mobility, and toileting but the care plan failed to specify the resident required two-person assistance. The deficient practice resulted in a fall incident with minor injury during provision of care. Findings include: Resident 124 (R124) R124 was admitted on [DATE], with diagnoses including adult failure to thrive, neuralgia and major depressive disorder. On 09/13/2023 at 9:46 AM, R124 recounted falling off the bed during care sometime in June 2023. The resident indicated being dependent on staff for care which was typically provided by two people but only one person provided care to the resident on the evening of the fall incident. The resident indicated slipping off the bed and sustained a minor injury to right eyebrow. An inter-disciplinary team (IDT) note dated 06/19/2023, documented R124 was transferred to the hospital following a witnessed fall resulting in a laceration to right eyebrow. Hospital staff informed the facility the resident's laceration was being sutured, computerized tomography (CT) scans were negative for injuries and R124 would be returning to the facility the same day. A Post-Fall assessment dated [DATE], revealed the resident slipped off the bed approximately two feet from surface to ground lying on abdomen. The resident sustained a laceration on right eyebrow measuring approximately one inch in length and 2.5 centimeters in depth. The admission minimum data set (MDS) dated [DATE], indicated R124 required total dependence by two persons for bed mobility, transfers, and toileting. R124's care plan initiated 02/16/2023, documented R124 required total assistance for bed mobility characterized by positioning and transferring related to weakness, impaired mobility, incontinence, and pain. The care plan did not specify whether R123 required one or two persons for activities of daily living (ADL) while in bed. The quarterly MDS dated [DATE], indicated R124 required extensive assistance by two persons for bed mobility, transfers, and toileting. The medical record lacked documented evidence R124's care plan was revised to reflect the resident required two persons for ADLs such as incontinence care. On 09/13/2023 at 12:14 PM, the Assistant Director of Nursing (ADON) indicated being familiar R124's fall incident on 06/19/2023 when a Certified Nursing Assistant (CNA) provided incontinence care alone without a second CNA to assist. The ADON indicated revising R124's care plan following the resident's fall on 06/19/2023 to reflect R124 required two persons during ADLs. The ADON reviewed the resident's MDS assessment history which specified R124 required extensive assistance by two persons as early as 02/14/2023 and acknowledged the resident' care plan failed to specify the resident required two-person assistance until 06/19/2023. On 09/13/2023 at 12:44 PM, the Resident Care Manager (RCM) indicated being assigned to R124 and personally completed the resident's MDS assessment and care plan. The RCM acknowledged R124's care plan failed to specify R124 required two persons until the care plan was revised after the fall incident on 06/19/2023. The RCM explained CNAs can view each resident's care plan on the Kardex so R124's fall was not caused by the CNA's failing to follow the care plan but rather the care plan was inaccurately written and inappropriately implemented which resulted in the resident's fall. The RCM acknowledged the inaccuracy was an oversight on the RCM's part. On 09/13/2023 at 1:30 PM, the ADON indicated the MDS assessment generates the resident's care plan, and the care plan must be consistent with the resident's assessment. The ADON indicated R124's fall from bed during ADL care was not caused by the CNA not following the care plan but rather the care plan inaccurately reflected the resident's functional status of requiring two persons instead of one for ADL care. The Person-Centered Comprehensive Care Plan policy revised August 2017 documented the comprehensive care plan was based on a thorough assessment which included the minimum data set (MDS). Assessments of residents were ongoing and care plans were revised to reflect any changes in the residents' condition. Each resident's person-centered care plan was designed to reflect the resident's functional status and functional levels.

Based on observation, interview, record review, and document review, the facility failed to ensure two-person assistance during incontinence care was provided as planned to prevent falls for 1 of 27 residents (Resident 289). This deficient practice led to a resident's fall with injury. Findings include: A facility policy titled Abuse, Neglect, and Exploitation - Clinical Protocol, dated 12/2020, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services necessary to prevent physical harm. A facility policy titled Using the Care Plan-Electronic Records, dated 11/2016, documented the care plan was used in developing the resident's daily care routines and was made available to staff personnel responsible for providing care or services to the resident. The completed care plan created a Kardex for immediate viewing access in the clinical record for nursing staff and other interdisciplinary team members involved in resident care and needs. The Kardex was accessible by Certified Nursing Assistants (CNAs) and Licensed Nurses within the electronic Point of Care (POC) stations. Resident 289 (R289) R289 was admitted on [DATE], and readmitted on [DATE], with diagnoses including muscle spasm, hemiplegia (a severe or complete loss of strength or paralysis on one side of the body), hemiparesis (one-sided paralysis) and cellulitis of the left lower limb. The Nursing admitted d 10/25/2022, documented R289 had weakness, multiple medical conditions, and a limited range of motion. R289 was dependent for the staff for bed mobility and activities of daily living (ADLs). A Care Plan dated 11/08/2022, documented R289 was totally dependent on mobility and characterized by the following functions: positioning, transferring, locomotion / ambulation related to mobility impairment, pain, and contractures. The interventions with bed mobility included required two-person total assistance. The Brief Interview of Mental Status dated 05/15/2023, documented a score of 15/15, which indicated R289's cognitive status was intact. The Minimum Data Set, dated dated dated [DATE], documented R289's bed mobility as extensive assistance with two-person physical assistance. A Physician Progress Note dated 04/18/2023, documented a fall incident was reported and R289 complained of left femur pain. X-rays were ordered and reviewed with an order to transfer R289 to the hospital. The facility Reported Incident documented, on 4/16/2023, R289 who had multiple medical issues, including wounds and contractures, rolled off the bed and sustained an injury when a Certified Nursing Assistant (CNA) repositioned R289 during incontinence care, without the help of another CNA. R289 was taken to the emergency roiagnom on [DATE] for further evaluation and treatment. The hospital History and Physical dated 04/18/2023, documented R289 was brought in via emergency from the facility after a ground-level fall. Per paramedic's report, R289 fell to the floor two days ago while R289 was being changed on the bed. R289 indicated the fall incident took place on Saturday, but a hip x-ray was not ordered until Sunday. A hip x-ray at the facility showed an acute fracture. The hospital consultation report dated 04/18/2023, documented an anterior / posterior and lateral radiograph of the knee was obtained, which appeared to show a nondisplaced fracture of the left medial condyle of the femur. The Impression documented, R289's status post fall with a left non-displaced medial condyle fracture. (a part of R289's left knee bone was broken. The break was not severe, and the bone pieces were still in their normal positions). On 09/14/2023 at 11:23 AM, a Registered Nurse (RN) revealed R289's level of care was high with transfer. An RN indicated R289 was approximately 200 pounds, very contracted, on low air loss mattress, and in a lot of pain. R289 required two-person assistance, as care planned. The RN indicated the assigned CNA worked at night and was probably rushing to complete the task before the end of the shift. On 09/14/23 at 11:30 AM, the Resident Care Manager (RCM) indicated during the investigation at the time, the CNA acknowledged being aware R289 required two-person assistance, but failed to call for help and provided the incontinence care alone. The RCM indicated poor judgment on the part of the CNA resulted in R289's fall and injury. The RCM indicated the required assistance was indicated in the Kardex, or care plan, and the staff were trained to look at and check the plan before providing care. The RCM indicated the CNA was familiar with the resident but failed to provide the required assistance indicated in the Kardex. The RCM indicated R289's fall could have been prevented if there had been two staff present as required. The CNA who was assigned to R289 no longer worked at the facility. On 09/13/2023 at 9:13AM, two CNAs indicated being familiar with which residents required one-person or two-person assistance. Both CNAs indicated the ADON and RCM reminded staff to follow the care plan following the fall incident. The CNAs were familiar with the resident's fall incident after one CNA provided care and was a night shift CNA who no longer worked at the facility. On 09/14/2023 at 12:30 PM, the Assistant Director of Nursing (ADON) and the Director of Nursing indicated the staff were expected to follow the resident's care plan to meet the resident's needs. The ADON confirmed R289 had a non-displaced fracture and no recommended treatment from the hospital, and R289 returned to the facility the same day. On 09/14/2023 at 1:14 PM, the Director of Rehabilitation Services (DOR) indicated R289 was bedbound, had limited range of motion with the upper extremities, and was totally dependent on staff for care. On 09/14/2023 at 1:29 PM, the Nurse Practitioner (NP) recalled R289 was bedbound and had assessed R289 following a fall incident. The NP indicated R289 was fully dependent on staff because of mobility issues. The NP indicated could not recall the reason for the fall, but the staff were expected to follow the required assistance to prevent fall. On 09/14/2023 at 1:56 PM, the Administrator indicated neglect was defined as when a care plan was not followed, or the necessary care was not provided. On 09/13/2023 at 9:15 AM, an RN recounted hearing of R289's fall incident, and the staff were reminded to review and follow the resident's care plan with regards to providing care. An RN was familiar with which residents required one or two-person assistance. On 09/14/2023 at 3:55 PM, during a telephone interview, the CNA who was assigned to R289 on the day of the fall incident on 04/16/2023, explained R289 was verbally alert, oriented, and bedbound. The CNA indicated being aware R289 required two-person physical assistance due to full dependence on repositioning and bed mobility. The CNA explained on the night of the fall could not get another staff for help and proceeded with the incontinence care, which resulted in R289's fall from the bed to the ground. The CNA indicated was standing on the door side, and R289 fell on the other side by the window side. The CNA indicated R289's fall could have been prevented if there had been two-person assistance. The facility Summary of Investigation of the R289's fall incident on 04/16/2023, revealed a CNA had not adhered to the care plan, which required two-person assistance for bed mobility. Following the investigation, it was determined the CNA's failure to follow the care plan had directly contributed to the accident. Complaint #NV00069293

Based on interview, record review and document review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form to 1 of 3 discharged residents (Resident 81). The deficient practice deprived the residents of their right to be informed of their Medicare coverage status and the appeal process. Findings include: Resident 81 (R81) Resident 81 (R81) was admitted on [DATE] with diagnoses including Parkinson's disease. The SNF Beneficiary Notification Review form revised October 2022, documented Medicare beneficiaries have specific rights and protections related to financial liability and the right to appeal a denial of Medicare services under the Medicare program. The financial liability and appeal rights and protections were communicated to beneficiaries through notices given by providers. The Beneficiary Notices Scenarios for Surveyors documented a SNF ABN and Notice of Medicare Non-Coverage (NOMNC) were required when a resident who had skilled benefit days remaining and was being discharged from Part A services and would continue living in the facility. A SNF ABN was a notice a provider provided before one received a service if, based on Medicare coverage rules, the provider had reason to believe Medicare will not pay for the service. A NOMNC was a notice that indicated when one's care was set to end from their Medicare covered benefit in a skilled nursing facility. A review of R81's medical record revealed a family member was identified as R81's Power of Attorney. A Patient Driven Payment Model (PDPM) Rate Report revealed R81 had Medicare A coverage from 01/24/2022 through 02/10/2022. The Physical Therapy Evaluation and Plan of Treatment documented a certification period from 02/03/2022 through 03/09/2022. The Physical Therapy Discharge Summary documented dates of service from 02/03/2022 through 02/10/2022. The NOMNC documented the effective date coverage for therapy services would end 02/10/2022. Three signatures, to include a family member, were dated 02/07/2022, which indicated the notice was received. The medical record lacked documented evidence a SNF ABN was provided prior to R81's skilled services ending. On 09/14/2023 at 10:49 AM, a Licensed Social Worker (LSW) explained the facility met weekly at a Utilization Review meeting to discuss when potential residents will no longer be covered by Medicare Part A in order to initiate the NOMNC and/or SNF ABN. The LSW indicated the SNF ABN would be filled out by a business office staff member who would send it to a Resident Care Manager (RCM), the RCM would meet with the resident or resident representative to get the SNF ABN signed, and the RCM would return the SNF ABN to the business office staff member. The LSW informed they spoke with a business office staff member and an RCM who were not able to explain why R81 did not have a completed SNF ABN. The LSW confirmed R81's medical record lacked documentation of a SNF ABN. On 09/14/2023 at 11:01 AM, Resident Care Manager 1 (RCM1) explained after the Utilization Review meeting, if a resident was identified, a business office staff member would email the necessary forms to the RCMs who would meet with the resident or resident representative to obtain signatures. Resident Care Manager 2 (RCM2) added RCMs would follow up to obtain a signature or verbal consent. Both RCMs confirmed R81's medical record lacked a SNF ABN and were not sure why one was not obtained. RCM 2 referred to R81's assigned Resident Care Manager 3 (RCM3) for any knowledge related to the SNF ABN. On 09/14/2023 at 11:22 AM, RCM3 explained they would generally receive the SNF ABN in an email from a business office staff member and proceed to meet with a resident or family member to obtain a signature or verbal consent over the phone. RCM3 indicated the SNF ABN was important for a resident coming off therapy as it gave a resident the opportunity the right to appeal the decision of ending therapy prior to services ending. RCM3 did not recall why a SNF ABN was not obtained on behalf of R81. On 09/14/2023 at 1:43 PM, the Administrator indicated the importance of the SNF ABN was to ensure residents were aware of services ending and having the right to appeal. The Administrator explained the facility did not have a policy for the beneficiary notice and provided a copy of the SNF Beneficiary Notification Review form revised October 2022, indicating that was what the facility referred to for the beneficiary notice. The Administrator verbalized according to the Beneficiary Notices Scenarios for Surveyors, R81 should have had both the SNF ABN and NOMNC. The administrator confirmed R81's medical record lacked a SNF ABN.

Based on observation, interview, record review, and document review, the facility failed to ensure physician orders for the care and maintenance of a suprapubic catheter (flexible tube used to drain urine from the bladder) were obtained for 1 of 27 sampled residents (Resident 389). The deficient practice had the potential to lead to infection and complications associated with catheter use. Findings include: Resident 389 (R389) R389 was admitted on [DATE] with medical diagnoses including malignant neoplasm (cancerous tumor) of bone and history of metastatic (spread of cancerous cells) prostate cancer with chronic suprapubic catheter. A Nursing Progress Note dated 09/07/2023 revealed R389 was admitted with a suprapubic catheter. A review of physician orders from 09/07/2023 through 09/13/2023 lacked documented evidence of orders for the care and maintenance of the suprapubic catheter for R389. On 09/14/2023 at 8:41 AM, a Registered Nurse (RN) explained there were standing orders for the care and maintenance of suprapubic catheters which were entered by either the nurses or the physicians. The RN indicated if there were no catheter care orders, the nurse was to call the physician and obtain new orders. The RN explained nurses documented the completion of catheter care in the Treatment Administration Record (TAR) and in nursing progress notes. The RN verbalized catheter care was done daily by the nurses and the care varied depending on the physician order. The RN explained general suprapubic catheter care included cleansing the insertion site with normal saline, either covering the site or leaving open to air, flushing the catheter, and changing the catheter bag monthly and as needed. The RN verbalized part of catheter care included assessing for signs of infection such as redness or discharge around the site, pink or red colored urine and any precipitate (crystals in urine which occur when too many minerals are in urine and not enough fluid) formation in the urine output. The RN indicated it was important to ensure catheter care was completed for infection purposes. On 09/14/23 at 9:03 AM, the Director of Nursing (DON) explained there needed to be catheter care orders for suprapubic catheters. The DON confirmed there were no orders for the care and maintenance of the suprapubic catheter for R389.

Based on observation, interview, and document review, the facility failed to provide Preventative Maintenance (PM) for 31 of 33 ventilators in use at the facility. The failure to provide preventative maintenance on the ventilators in a timely manner could lead to machine malfunction impacting a resident's respiratory care and cause potential physical harm. Findings include: On 02/01/2023 at 8:37 AM, a tour with the Director of Respiratory Services revealed the following: A resident in room [ROOM NUMBER] was on a ventilator. The PM sticker located on the ventilator documented the last PM had been completed in 2018 and the PM was due in 01/2020. Two residents in room [ROOM NUMBER], were on ventilators. The PM sticker located on the ventilator for one bed documented the last PM had been completed in 01/2020 and was due in 01/2022. The PM sticker located on the ventilator for the other bed documented the last PM had been completed in 08/2019 and was due in 08/2021. On 02/01/2023 at 10:46 AM, the Director of Respiratory Service revealed the facility had a total of 37 ventilators in the facility with 33 ventilators being used by residents. Of the 37 ventilators, there were 31 ventilators behind on their PM. The ventilators PM should be conducted yearly or every 2 years. The time frame for the PM would depend upon the number of hours the ventilator had been used, or the date located on the machine's sticker specifying when the PM was due. The Director of Respiratory Service indicated the PM was to be done every two years per the manufacturer's instructions. On 02/01/2023 at 8:13 AM, the Director of Plant Operations/Maintenance, explained some equipment were inspected by the maintenance department and others were maintained through contracted companies. The respiratory team oversaw the ventilators which are also contracted out. On 02/02/2023 at 8:28 AM, the Director of Respiratory Services provided an e-mail to the Bureau with an updated count of 32 residents on a ventilator, 11 ventilators were rented, 15 ventilators were due for preventative maintenance, and the facility had four backup ventilators. The facility's policy for preventative maintenance, dated 08/03/2022, lacked detailed information regarding how and by whom the equipment was serviced, when the equipment was serviced, the frequency of service, what was included in the preventative maintenance check, tracking of which equipment was serviced, and how the equipment was maintained. Complaint # NV00067366

Based on observation, interview, and document review, the facility failed to ensure resident equipment received preventative maintenance and were labeled with PM completed or due dates (Oxygen concentrators, Suction Machines and Feeding Pumps). The failure to maintain the resident equipment could lead to equipment malfunction impacting its effectiveness during resident care. Findings include: On 02/01/2023 at 8:13 AM, the Director of Plant Operations/Maintenance explained some of the resident's equipment were inspected by the facility's maintenance department and others were maintained through contracted companies. On 02/01/2023 at 9:17 AM, a Maintenance Supervisor revealed the facility's maintenance department conducted annual visual checks for the oxygen concentrators and suction machines. Oxygen Concentrators: If repair services were needed for the oxygen concentrator, the facility would send the equipment out to their contracted vendor for repair. The sticker date on the oxygen concentrator indicated when the equipment was returned to the facility after being serviced/repaired. On 02/01/2023 during a tour with the Director of Plant Operations/Maintenance, the following dates on the oxygen concentrators were identified: In resident room [ROOM NUMBER], the oxygen concentrator for one resident was last returned to the facility after being serviced/repaired on 03/15/2020, and for the other resident was on 04/27/2021. In resident room [ROOM NUMBER], the oxygen concentrator for one resident was last returned to the facility after being serviced/repaired on 07/08/2020, and for the other resident was on 05/10/2018. In resident room [ROOM NUMBER], the oxygen concentrator for one resident was last returned to the facility after being serviced/repaired on 03/2022, and for the other resident was on 06/30/22. Suction Machines: On 02/01/2023 in the morning, the Director of Plant Operations/Maintenance and a Maintenance Supervisor verbalized the suction machines were thrown away if they were damaged. In addition, a Maintenance Supervisor explained the facility had started to put a sticker with a date on the newly replaced suction machines since July 2022, however, not all have been completed. On 02/01/2023 during a tour with the Director of Plant Operations/Maintenance, it was confirmed in resident rooms 1176, 1178, 1182 and 1190, there was a total of six suction machines that did not have a sticker or a date on the machine to indicate PMs had been completed. A review of the manufacturer's manuals provided by the facility for the oxygen concentrators and suction machines lacked documentation regarding how often the preventative maintenance should be completed. Feeding Pumps: On 02/01/2023 at 9:17 AM, a staff member from Central Supply verbalized the facility staff members conducted an annual rotation to switch out the old feeding pumps with new feeding pumps that were provided to the facility at the end of the year. The staff member from Central Supply later reported the maintenance for the feeding pumps was conducted every two years per the manufacture manual. The old feeding pumps were sent to a third party who would forward the feeding pumps to the manufacturer company. The year on the maintenance sticker indicated the year the feeding pump was switched out. On 02/01/2023 during a tour with the Director of Plant Operations/Maintenance, it was confirmed in resident rooms 1172, 1178, 1182 and 1190, there were a total of seven feeding pumps which were dated in 2021 and 2022. A request was made for the facility to provide manufacturer's manual for the feeding pumps. The facility did not provide the manufacturer's manual for the feeding pumps as requested. On 02/01/2023 at 9:40 AM, the Director of Plant Operations/Maintenance explained starting in July 2022, the maintenance department had been in the process of checking which equipment required preventative maintenance. He acknowledged the facility lacked detailed documentation to know which specific equipment had been inspected or serviced. The Director of Plant Operations/Maintenance confirmed the facility's PM policy lacked documentation as to what resident equipment required PM, who was responsible for the PM, when the PM was due for each piece of resident equipment, and a way to track the resident equipment. The Director of Plant Operations/Maintenance confirmed the facilities Electrical Rounds documentation dated 05/2022, included the resident room numbers and a check list of what was completed. The documentation did not specify whether the equipment was a suction machine, oxygen concentrator or feeding pump. There was documentation the facility tracked the equipment maintenance by the resident room number and not by the machine's serial number. A review of the Maintenance Schedules Policy (undated) documented the Maintenance Director was responsible for developing and maintaining a schedule of maintenance, a maintenance schedule shall be provided to each department director, and maintenance personnel shall follow manufacturer's recommended maintenance schedule. Complaint # NV00067366

Based on observation, interview and record review, the facility failed to ensure residents received regular repositioning to avoid pressure ulcers for 3 of 15 sampled patients (Resident #1, #6 and #14). Findings include: Facility policy titled "Using the Care Plan - Electronic Records", dated 5/2010, documented the following: "Policy Statement- The care plan shall be used in developing the resident's daily care routine and will be available to staff personnel who have responsibility for providing care or services to the resident. ... 7. Documentation must be consistent with the resident's care plan". Facility policy titled, "Repositioning", revised date 5/2010, documented the following: General Guidelines: ...3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. Interventions/Care Strategies: 1. Standards of are (sic) (See Marquis Standards of Care doc.) is that residents are assisted with repositioning every 2 hours, unless defined as independent, and as needed. 2. An individualized and specific turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. 3. Residents should be turned as often as determined as needed by skin at risk assessments and the residents care plan. Facility policty titled, "Prevention of Pressure Ulcers", revised date 11/2012, documented the following: General Preventative Measures:... 2. For a person in bed: a. Change position at least every two hours or more frequently if needed. Risk Factor: Bed Fast: a. Change position at least every two hours and more frequently as needed. On 10/31/13 at 10:05 AM, the Wound Care Nurse revealed the CNA's (Certified Nursing Assistants) know if the resident was facing the door, they should be turned toward the window in two hours. The Wound Care Nurse indicated the CNA's did not document the turning schedules. Additionally, the Wound Care Nurse verbalized the charge nurses and wound care nurse routinely monitored the halls and asked the CNA's to confirm if residents were being turned. On 10/31/13 at 11:10 AM, Employee #11, a LN (Licensed Nurse), explained the CNA's had a schedule for turning the residents and it was mandatory for the CNA's to turn the residents every two hours. The LN revealed the nurses monitor the hall to ensure residents were turned and document in the progress notes that resident was turned, but not how often. On 10/31/13 at 12:25 PM, Employee #13, a CNA (Certified Nursing Assistant) revealed the residents were turned every two hours. The CNA explained the nurses monitor the residents being turned by asking the CNA's. The CNA revealed the turns were not documented on the resident's record, but had a sheet of paper used to document throughout the day to remind them when the resident was due to be turned. The paper was then shredded at the end of the day. Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Care Plan dated 7/31/13 documented, "Turn and reposition at least q (every) 2 hours". On 10/30/13 at 10:00 AM, the resident was observed to be lying in bed on the right side. On 10/30/13 at 11:30 AM, the resident was observed to be lying in bed on the left side. On 10/30/13 at 2:20 PM, the resident was observed to be lying in bed on the left side. A family member at the bedside advised had not seen a nurse or CNA since arriving in the resident's room. Resident #6 Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Braden Scale dated 10/17/13, documented, "Mobility- Completely immobile: Does not make even slight changes in body or extremity position without assistance." A Skin Event assessment dated [DATE], documented, "Reopen pressure ulcer to sacral area". Progress note dated 10/9/13, documented, "Wound has reopened. Measures 1.5 x 1.5 x 0.5 cm., 100% granulated tissue with min serous drainage. Periwound is pink scar tissue. Cleanse wound pat dry apply collagen and foam drsg (dressing) daily and PRN (as needed). Air mattress in place for aid in wound healing. Offload using pillows and turn side to side frequently". On 10/31/13 at 10:05 AM, the Wound Care nurse acknowledged the pressure ulcer had re-opened on 10/5/13. Review of Care Plan dated 10/17/13, documented, "Turn and reposition at least q 2 hours". On 10/30/13 at 8:23 AM, the resident was observed to be lying in bed on the right side. On 10/30/13 at 9:21 AM, the resident was observed to be lying in bed on the right side. On 10/30/13 at 11:27 AM, the resident was observed to be lying in bed on the right side. On 10/30/13 at 12:43 PM, the resident was observed to be lying in bed on the left side. Resident #14 Resident #14 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Care Plan dated 10/19/13 documented, "Turn and reposition q 2 hours". A Skin Event assessment dated [DATE] documented, "Boil to right and left labia. Turn and reposition at least q 2 hrs.". On 10/29/13 at 12:20 PM, the resident was observed to be lying in bed on the left side. On 10/29/13 at 1:10 PM, the resident was observed to be lying in bed on the left side. On 10/29/13 at 2:20 PM, the resident was observed to be lying in bed on the left side. On 10/29/13 at 3:16 PM, the resident was observed to be lying in bed on the left side.

Based on observation, interview and record review, the facility failed to provide wound care as ordered for 2 of 5 sampled residents (Residents #9 and #2) and 1 unsampled resident (Resident #44) for whom wound care was observed. Resident #2 Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was non-verbal and unable to communicate. Documentation in Resident #2's electronic medical record (EMR) revealed the resident had developed a new pressure ulcer on the right ear and as of 8/4/13 there was a physician's orders [REDACTED]. On 8/6/13 at 7:30 AM, Resident #2 was observed in a right side-lying position with the right side of the head on the pillow. On 8/7/13 at 9:55 AM, Resident #2 was observed in a left side-lying position. The middle helix surface (front side of the outer rim) of the resident's right ear was noted to be red and swollen. On 8/7/13 at 4:08 PM, Resident #2 was observed in a right side-lying position with the right side of the head on the pillow. On 8/7/13 at 5:00 PM, Resident #2 was observed in a right side-lying position with the right side of the head on the pillow. On 8/8/13 at 8:30 AM, Resident #2 was observed in a right side-lying position with the right side of the head on the pillow. The respiratory therapist had just drawn blood from the resident's right wrist. On 8/8/13 at 11:00 AM, Resident #2 was observed in a right side-lying position with the right side of the head on the pillow. On 8/8/13 at 2:25 PM, Resident #2 was observed in a right side-lying position with the right side of the head on the pillow. On 8/9/13 in the afternoon, Resident #2 was in a right side-lying position with the right side of the head on the pillow. The family member was at the bedside and assisted Employee #18 with holding the resident in position while wound care was provided to the coccyx pressure ulcer. Employee #18 assessed Resident #2's left gluteal fold (buttock) and identified a new stage II pressure ulcer and explained, "It wasn't there yesterday." While walking to the treatment cart, the inspector asked about Resident #2's status on the previous day. Employee #18 accessed the documentation in the electronic medical record and read the entry for 8/8/13 which said: "Wound care was done at 9:09 AM, changed the diaper and light brown, runny stool (no odor) was still coming out ... left resident on the right side ... " The inspector explained the observations made on 8/8/13, and asked Employee #18 if being left in the same position with runny feces in a soiled diaper for five hours could have caused Resident #2's new pressure ulcer. The employee replied, "Yes, it's safe to say that." On 8/12/13 at 8:15 AM, Resident #2 was observed in a right side-lying position with the right side of the head on the pillow. At 12:15 PM, the resident was in the same position. At 12:20 PM, the inspector spoke with the licensed practical nurse (LPN) responsible for the resident's care. The LPN was unaware the resident's right ear was to be offloaded. The Director of Nursing (DON) and the certified nursing assistant (CNA) were called to Resident #2's room and shown the resident's right ear. The affected area was red, swollen and moist. The DON and CNA were interviewed regarding the right ear pressure ulcer and the physician's orders [REDACTED]. The CNA admitted she had not checked the Kardex and was unaware of the right ear needing to be offloaded. As we left Resident #2's room, the DON explained the CNA had "just returned from vacation." Resident #2's Schedule for August 2013 (physician's recapitulation of orders) documented, "... off load right ear q (every) shift for skin impairment." This physician-ordered care was initiated on 8/4/13, three days after the resident was admitted . The facility's policy, Repositioning, revised 05/10, documented the following: "The purpose of this procedure is to provide guidelines for the assessment of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. ... 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. ... 5. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. ... 17. Turn and reposition every 2 hours. ..." 1. Standards of are (sic) (see Marquis Standards of Care doc.) is that residents are assisted with repositioning every 2 hours, unless defined as independent, and as needed. 2. An Individualized and specific turning/repositioning program includes continuous consistent program for changing the resident's position and realigning the body. A program is defined as a specific approach that is organized, planned, documented, monitored and evaluated. 3. Resident should be turned as often as determined as needed by skin at risk assessments and the residents care plan. 4. If ineffective, the turning and repositioning frequency will be increased. ..."