Every finding on record at Mountain View Care Center

Based on recorded review, interview and document review the facility failed to ensure physician orders were followed for the treatment of hypoglycemia (low blood sugar) and the physician notified of a change of condition for 1 of 20 sampled residents (Resident 52). The deficient practice had the potential to lead to worsened symptoms of hypoglycemia, hospitalization, or even death.Findings include: Resident 52 (R52) was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema.A review of R52's weights and vitals summary dated 10/21/2025 through 10/31/2025 documented a blood sugar value of 43 milligrams per deciliter (mg/dL), a unit for measuring substance concentration (like blood sugar) on 10/29/2025. The summary documenting a warning low of 70.2 mg/dL exceeded.A review of R52's Medication Administration Record (MAR) revealed an order for Glucose Gel 15 grams/32 milliliter (GM/ML) (a fast-acting sugar solution used to treat low blood sugar). Give 15 grams by mouth as needed (prn) for a blood sugar below 60 for conscious patients. Start date 06/07/2025.The MAR lacked documented evidence Glucose Gel 15 GM/32ML was given as ordered for blood sugar under 60 mg/dL. On 12/04/2025 at 3:42 PM, a Licensed Practical Nurse (LPN), verified R52's glucose level was 43 mg/dL and Glucose Gel was not administered. The LPN stated R52's blood sugar should have been retaken 15 minutes after the initial test. The LPN a change in condition was completed or the provider notified regarding R52's low blood sugar. On 12/05/2025 at 7:28 AM, a Unit Manager confirmed R52s initial glucose level was 43 mg/dL and Glucose Gel was not administered. The Unit Manager clarified R52 blood sugar should have been re-checked within 15 minutes, a change in condition documentation completed and the provider notified regarding to R52s blood sugar levels. On 12/05/2025 at 7:30 AM, the Unit Manager provided standing orders document titled for Diabetic Management, located on each medication cart documented to give Glucose Gel 1 tube orally if blood sugar less than (<) 60 for conscious patients, call primary care provider (PCP) to review insulin orders. Recheck blood sugar in 15 minutes, if the sugar has not increased call 911 and the PCP. If the blood sugar has increased but is still <60 give another dose of Glucose. On 12/05/2025 at 8:00 AM, the Director of Nursing (DON), verified R52s glucose level was 43 mg/dL and Glucose Gel was not administered. The DON stated a blood sugar re-take was necessary and a four-hour delay from the initial blood sugar check should not have happened. The documentation was not present and the provider needed to be contacted for low and high blood sugar levels. On 12/05/2025 at 8:51 AM, a Clinical Resource Nurse confirmed the assigned nurse did not Glucose Gel for R52s low blood sugar of 43 mg/dL and a blood sugar re-take was needed, documentation should have been present and the provider contacted for the low and high blood sugar readings. Facility policy titled Administering Medications, revised April 2019, documented medications were administered in accordance with prescriber orders, including any required time frame. Facility policy titled Change in Residents Condition or Status, revised February 2021, documented the nurse will notify the attending physician or physician on call when there has been specific instruction to notify the physician of changes in the resident's condition.

Based on interview, record review, and document review, the facility failed to ensure a pharmacist's recommendation for a gradual dose reduction (GDR) was act upon for 1 of 20 sampled residents (Resident 30). The deficient practice had the potential for significant side effects including drowsiness, blurred vision, fatigue, trouble sleeping, and changes in mood. Findings include:Resident 30 (R30) was admitted [DATE], readmitted [DATE], with diagnosis including phantom limb syndrome with pain, major depressive disorder recurrent moderate and dementia unspecified severity with agitation.A physician order dated 10/18/2025, documented Fluoxetine Hydrochloride (HCI) oral capsule 40 milligrams (mg), give one capsule by mouth one time a day, related to major depressive disorder recurrent moderate. Record review revealed R30 had been receiving the same dose of Fluoxetine HCI 40 mg since 08/18/2023.A Medication Regimen Review dated 09/29/2025, documented a recommendation from the consultant pharmacist to consider a trial dose reduction to Fluoxetine 20 mg daily. The Physician/Prescriber section of the form indicated the Agree box was checked and the practitioner's signature was dated 10/24/2025.R30's electronic medical record lacked evidence the Fluoxetine dose was reduced as agreed upon by the practitioner.On 12/03/2025 at 3:33 PM, the Medical Records Coordinator stated GDR forms were sometimes given to the nurses and sometimes to the Director of Nursing (DON). The Medical Records Coordinator was unsure why R30's GDR form did not reach the DON and was instead filed in the medical record. The Medical Records Coordinator acknowledged the signed GDR recommendation should have been provided to the DON for review rather than filed without action.On 12/03/2025 at 4:11 PM, the Consultant Pharmacist explained the recommendation for a dose reduction was made because R30 had been receiving Fluoxetine 40 mg for over one year. The Consultant Pharmacist reported a gradual dose reduction would have helped ensure R30 was not taking more medication than necessary.On 12/03/2025 at 4:20 PM, the DON explained completed GDR forms signed by the practitioner were to be given to the records department and then routed to the DON for processing. New medical records staff members were not fully clear on the process and filed the signed form in the medical record. The signed GDR form had not reached the DON for review and not acted on to clarify the order or process the recommended change. A GDR was to ensure the resident was on the lowest therapeutic dose while still having the intended benefits of the medication.A facility policy titled Tapering Medications and Gradual Drug Dose Reduction, Revised July 2022, documented residents who used psychotropic medications received gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue these drugs.

Based on observation, record review, interview, and document review, the facility failed to ensure the medication error rate was less than five percent (%) resulted in a medication error rate of 6.67%. This deficient practice had the potential to put the resident at risk for adverse drug reactions, ineffective treatment, and compromised health outcome.Findings include:On 12/03/2025 at 7:40 AM, Licensed Practical Nurse (LPN4) was observed preparing medications for Resident 61 (R6). LPN4 administered Aspirin 81 milligrams (mg) chewable, 1 tablet and Losartan Potassium 50 mg 1 tablet orally to R61. R61 was admitted on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD) and essential hypertension.A physician order dated 11/19/2025 indicated, Aspirin Oral Capsule 81 mg, give 1 tablet by mouth once daily for deep venous thrombosis.A physician order dated 11/22/2025 Losartan Potassium 100 mg 1 tablet by mouth one time a day for hypertension.On 12/03/2025 at 7:50 AM, the LPN acknowledged the discrepancies and stated the physician orders should have been verified prior to administration.The facility's policy titled Administering Medications, last revised April 2019, directed staff administering the medications to verify the right medication and right dosage. The policy indicated medications should be administered in accordance with prescriber orders.

Based on observation, interview, and record review, the facility failed to ensure 1) safe and sanitary medication administration practices for 1 of 3 residents (Resident 61) during the medication pass observation, and 2) the Water Management Program included all requirements to prevent the growth and spread of Legionella. This deficient practice had the potential to compromise resident safety by increasing the risk of infection and cross contamination during medication administration, and exposure to waterborne pathogens.Findings include:Resident 61(R61) was admitted on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD). On 12/03/2025 at 7:40 AM, during a medication administration observation a Licensed Practical Nurse (LPN), retrieved a new bottle of aspirin intended for R61. The LPN used a bare finger to remove a tablet from the container. The inspector directed the LPN to discard the tablet since it was contaminated after being touched with a bare finger. During this process, four aspirin tablets fell onto the surface of the medication cart. The LPN returned the contaminated tablets to the original bottle instead of discarding them. On 12/03/2025 at 7:50 AM, the LPN performed a blood glucose test on R61. Upon completion, the LPN placed the used blood glucose meter into their scrub pocket without disinfecting the device. On 12/03/2025 at 9:30 AM, the LPN acknowledged the four aspirin tablets were contaminated after falling onto the medication cart surface and should have been discarded and the blood glucose meter should have been disinfected after use and not stored in a pocket. On 12/05/2025 at 11:30 AM, the Director of Nursing (DON) acknowledged the blood glucose meter should have been disinfected before and after each use to prevent the transmission of bloodborne pathogens and stored in the LPN's pocket, as this practice increases the risk of cross-contamination and resident exposure. The DON verbalized the LPN should not have handled aspirin tablets with bare hands, and tablets should have been discarded in accordance with infection control protocols. The facility policy titled Administering Medications, last revised April 2019, documented staff administering medications should follow established infection control procedures such as hand hygiene and antiseptic technique. The facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, last revised September 2022, indicated resident-care equipment, including reusable items should have been cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations. CDC recommendation titled Considerations for Blood Glucose Monitoring and Insulin Administration dated 08/07/2024, documented blood glucose meters should be cleaned and disinfected after every use, per the manufacturer's instructions. The manufacturer's instructions for the blood glucose meter recommended the use a disinfectant approved by the United States Environmental Protection Agency (EPA) to be used in clinical settings. A review of the facility policy titled Legionella Water Management Program (LWMP), last revised in July 2017, identified the composition of the Water Management Team and the appropriate standards or recommendations on which the plan was based. The LWMP outlined a number of elements that were to be written into the plan. These included an interdisciplinary water management team, the standards used for the development and implementation of the LWMP based on CDC and ASHRAE recommendations, and a detailed description and diagram of the water system in the facility in both written and illustrated form. The plan also included the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situations that could lead to Legionella growth, and specific measures used to control the introduction and/or spread of Legionella. In addition, the plan addressed the control limits or parameters that were acceptable and monitored, a system to monitor control limits and the effectiveness of control measures, a plan for when control limits were not met and/or control measures were not effective, and documentation of the LWMP. The LWMP also outlined that the plan would be reviewed annually or sooner if control measures were not met, major maintenance or water service changes occurred, associated disease cases were identified from the water system, or if there were changes in laws, regulations, standards, or guidelines. On 12/04/2025 in the morning, a detailed review of the LWMP policy revealed the following elements were not provided, specified, or followed as outlined. The LWMP, referred to as the plan, included a written narrative of the water flow in the building but did not include an illustrated flow diagram for the path of water through the facility. The plan stated the LWMP will be reviewed at least once a year, or sooner. The plan provided during this survey was dated July 2017, and no information was received that indicated the plan had been reviewed since 2017. The plan indicated control measures would be monitored. The control measures included weekly water temperature checks and inspection of water fixtures for biofilm (slime). However, the plan did not define details of the required hot water temperature range, where the temperatures would be taken, and how or where to document the water temperatures. The plan also did not define the water fixtures to check, their locations, or the frequency of inspections. The plan indicated there were ways to intervene when control limits were not met. However, those ways included taking corrective action, limiting the risk to residents, and testing the water system until normal conditions returned. The plan did not define the specific corrective actions that could be taken, nor did it define the meaning of testing the water system or normal conditions. The plan indicated that water heaters would be inspected and the results recorded. However, there were no specific instructions on what the water heater was being inspected for or how the results were to be recorded. On 12/04/2025 morning, the Maintenance Director (MD) stated there were no written records of water fixture inspections, except for ice machine cleanings provided on 12/05/2025. The MD confirmed there were no documented records of water heater inspections. The MD explained the facility flushed seldom-used fixtures and adjusted water temperatures but did not document these actions or results. The MD also stated the facility did not use disinfectants in the water system. On 12/04/2025 morning, the Infection Preventionist confirmed the facility had not had any residents with Legionella since the last survey.

Based on observation, interview, record review, and document review, the facility failed to ensure residents' tube feeding (TF) orders were followed and completely delivered as ordered for 3 of 5 sampled residents (Residents 54, 48, and 11). The deficient practice could have led to a potential risk of malnutrition, dehydration, and inadequate caloric intake, compromising residents' health and increasing susceptibility to further medical complications. Findings include: A facility policy titled Enteral Nutrition revised February 2008, documented adequate nutritional support through enteral nutrition was provided to residents as ordered. A facility policy revised February 2008 documented the adequate nutritional support through enteral nutrition was provided to residents as ordered. Examples of potential benefits from using a feeding tube included addressing malnutrition and dehydration, promoting wound healing, allowing residents to regain strength, and enabling a transition back to oral nutrition. Resident 54 (R54) R54 was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia, vitamin deficiency and gastro-esophageal reflux disease. A Physician order dated 05/18/2024 documented Glucerna 1.2 at 60 milliliters per hour (ml/hr), with free water flush (FWF) at 30 ml/hr, to run for 21 hours, providing 1,512 kilocalories (kcal), 76 grams of protein (1,014 + 630), and 1,644 ml of water per day. Off at 10:00 AM, on at 1:00 PM. A Care Plan dated 08/22/2023. documented R54 had bowel/gastrointestinal disorders or diseases, including bowel incontinence, decreased mobility, dysphagia, gastrostomy tube (GT) for nutrition, gastroesophageal reflux disease, risk of dehydration, and potential fluid deficit. Interventions included administering medications as ordered. A Care Plan dated 08/22/2023, documented R54 required tube feeding related to at risk for dehydration, at risk for potential fluid deficit, CVA, dysphagia, swallowing problem. The interventions included to administer TF and water flushes per MD orders. The goal included R54 would maintain adequate nutritional and hydration status AEB weight stable, no s/s of malnutrition through review date. The Nutritional assessment dated [DATE], documented R52 was on TF Glucerna 1.2 at 60 ml/hr x 21 hrs., via gastrostomy tube (GT) to provide 1512 kcals, 76 g protein, 1650 ml water total. FWF at 30 ml/hr x 21 hrs.; off at 10 AM on at 1:00 PM. R54 was slightly overweight, and weight maintenance was desired. On 10/29/2024 at 11:31 AM, R54 was in bed, awake, non-verbal and incoherent. Enteral pump was at bedside, no tube feeding (TF) was infusing at this time. The gastrostomy site (GT) was covered with a dressing. On 10/31/2024 at 10:05 AM, the tube feeding (TF) of Glucerna 1.2 was infusing at 60 ml and free water flush (FWF) at 30 ml. A Licensed Practical Nurse (LPN) entered R54's room and turned off the enteral pump. The LPN indicated the TF should have been turned off at 10:00 AM and turned back on at 1:00 PM. The LPN verified the enteral pump history, reviewing the total TF volume delivered, and revealed the following: -12 hours: TF 686 ml, FWF 360 ml -24 hours: TF 1241 ml, FWF 660 ml -48 hours: TF 2251 ml, FWF 1237 ml -72 hours: TF 3414 ml, FWF 1867 ml On 10/31/2024 at 10:09 AM, a Registered Dietitian (RD) indicated R54 was on nothing by mouth and prescribed a continuous TF of Glucerna 1.2 at 60 ml/hr, with supplemental water at 30 ml/hr, scheduled to run for 21 hours, pausing at 10:00 AM and resuming at 1:00 PM. The RD confirmed R54 was tolerating the TF well, maintaining a stable weight and showing a body mass index (BMI) of 28.1, which indicated a slight excess but no significant changes in weight. The RD confirmed R54's TF orders were not followed, and the prescribed volume was not fully delivered, increasing the potential risk of nutritional deficits. The RD indicated R54 was supposed to receive 3,780 ml over 72 hours; a shortage of 366 ml represented a significant dose and exceeded the lower end of R54's daily requirements. Resident 48 (R48) R48 was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), gastrostomy, and dementia. A Physician order dated 04/28/2024 documented Jevity/Isosource 1.5 at 55 ml/hr and FWF at ml/hr to run for 21 hours. Off at 8:00 AM and on at 11:00 AM. The Nutritional assessment dated [DATE], documented R48 was on TF Jevity 1.5 at 55 ml/hr x 21 hrs., via gastrostomy tube (GT) to provide 1733 kcals, 73 grams protein, and (878 + 945), 1823 ml water. The goal was to maintain body weight and continue to meet R48's daily needs. A Care Plan dated 11/03/2023, documented R48 required tube feeding related to at risk for dehydration, potential fluid deficit, and dysphagia. The interventions included administering the feeding as ordered. On 10/31/24 11:07 AM, R48 was in bed with eyes closed, and TF Jevity 1.5 was infusing at 55 ml/hr. The LPN confirmed the TF pump history for 72 hours, indicating a total volume delivered of 3062 ml. On 10/31/2024 at 11:15 AM, the RD verified R48's TF pump history and noted the total dose delivered was only 3062 ml, while 3465 ml was intended for 72 hours. The RD indicated a discrepancy of 403 ml over 72 hours, representing a significant dose that exceeded the lower end of R48's daily requirements. The RD indicated this discrepancy could potentially lead to nutritional deficits over time and verbalized the TF order should have ensured complete delivery of the TF dose. The RD indicated R48 had no significant weight change for the last 60 days. On 10/31/2024 at 2:57 PM, the Nurse Practitioner (NP) indicated being unaware the resident's TF dose was not fully administered. The NP indicated the TF orders should have been administered as ordered to ensure adequate nutrition. 29141 Resident #11 (R11) R11 was admitted on [DATE], with diagnoses including dysphagia, dementia, and seizure disorder. The resident had a gastrostomy tube (G-tube used as artificial route to provide enteral nutrition directly to the stomach). Physician's order dated 10/04/2023, documented enteral feed formula Glucerna 1.2 calories (Cal) per milliliter (ml) to be administered at 60 milliliters per hour (ml/hr) for 24 hours, for a total of 1,440 ml. On 10/30/2024 in the morning, a review of the enteral pump 72 hours memory history revealed 3,666 ml of formula was delivered in the previous 72 hours. This amount had a discrepancy with the physician's order since 4,320 ml should had been administered (60 ml X 72 hours = 4,320 ml/h), indicating R11 missed about 654 ml of formula (750 Cal). On 10/31/2024 in the morning, the RD confirmed R11's enteral nutrition order was not followed, and the prescribed volume was not completely delivered, with a deficit of 654 ml of formula (750 Cal), impacting the prescribed calorie requirements.

Based on observation and interview, the facility failed to label, and date open stored food products, and maintain sanitary conditions in the kitchen. The deficient practice could potentially expose residents to foodborne illnesses. Findings include: On 10/29/24 at 8:15 AM, an inspection was conducted in the kitchen with the kitchen manager. The following issues were identified: -The coffee machine and the iced tea dispenser had visible ground coffee residue and appeared dirty. - Two ovens were visibly soiled with substantial accumulations of grease and burned food debris. The kitchen manager indicated the ovens were scheduled to be deeply cleaned and acknowledged the ovens should had been cleaned more often. - Two trays and a cart containing cartons of milk and chocolate milk were visibly soiled with dairy matters. - The kitchen floor, including the food preparation area, under the steam table, stove, and dishwashing area, was visibly soiled with food debris and grease. The kitchen manager admitted the kitchen was cleaned every two weeks and acknowledged it should have been cleaned more frequently. The following issues in food products were identified: - A bag of lettuce dated 10/11/2024, was visibly mushy and had turned a yellowish color, indicating the lettuce was no longer fresh. The kitchen manager indicated the lettuce should have been disposed after two weeks upon received. - Two glasses of non-dairy milk not dated. - An open bag of shredded cheddar cheese was not dated. - An open gallon of whole milk was not dated. - An open half gallon of reduced fat milk lactose free was not dated. - An open container of chopped garlic, 2 pounds was not dated. The kitchen manager confirmed the observations and verbalized open food products should have been labeled and dated upon initiated. The facility policy titled Food Storage: Cold Foods, dated April 2018, documented all foods would be stored labeled and dated. The facility policy titled Environment dated September 2017, indicated all food preparation areas, food service areas, and dining facilities would be maintained in a clean and sanitary conditions. The policy stated the Dining Services Director (kitchen manager) would ensure the kitchen was maintained in clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.

Based on observation, interview, record review, and document review, the facility failed to ensure: 1) Signage for Enhanced Barrier Precaution (EBP) was posted for a resident with a urinary catheter and an unstageable wound, and personal protective equipment (PPE) was available (Resident 82), 2) Gown was used by staff when providing direct care to residents on precautions, and hand hygiene was performed after removing the used gloves (Resident 63); and 3) a policy was in place regarding the reuse of gowns after use. This deficient practice had the potential to increase the risk of cross-contamination, the spread of healthcare-associated infections, and compromise infection control measures. Findings include: 1) Resident 82 (R82) R82 was admitted on [DATE] and readmitted on [DATE], with the diagnoses including urinary tract infection, acute kidney infection, unstageable pressure ulcer and urinary retention. On 10/30/2024 at 10:45 AM, R82 was in bed with eyes closed, a Foley catheter was covered yet visible from the doorway. There was no EBP sign posted in R82's room, nor was any personal protective equipment available by the door. A Certified Nursing Assistant (CNA) indicated R82 had been on a Foley catheter since admission and was under hospice care. The CNA indicated R82 had open wounds, which were being treated by the Wound Care Treatment Nurse (WCTN). On 11/01/2024 at 10:15 AM, a hospice Registered Nurse (RN) was inside R82's room, providing care with a surgical mask and gloves but without a gown. The hospice RN confirmed providing direct care by obtaining vital signs, conducting a body assessment, checking the Foley catheter, and assisting R82, all without a gown. The hospice RN explained being unfamiliar with the facility protocol regarding EBP and provided care without a gown due to the absence of signage and no available gown. The hospice RN indicated a precaution sign and PPE should have been readily available for compliance and to prevent cross-contamination. 2) Resident 63 (R63) R63 was admitted in 11/02/2022, with diagnoses including dementia and pressure ulcer stage 4. On 11/01/2024 at 11:05 AM, signage for EBP was posted in R63's room door, with two cloth gowns hung on a wall hook labeled #1 and #2. Certified Nursing Assistant 1 (CNA 1) and Certified Nursing Assistant 2 (CNA 2) were providing incontinence care to R63 with a draining wound and a Foley catheter. Both CNAs wore gloves but did not wear gowns. Both confirmed no gown was worn while cleaning R63. CNA 1 removed the gloves but did not perform hand hygiene. CNA 1 confirmed hand hygiene was not performed after glove removal. 3) On 10/29/2024 and 11/01/2024 in the morning, CNAs and WTCN were observed providing care and reusing the yellow cloth gowns hung on the wall numbered # 1 and # 2. On 11/01/24 at 10:38 AM, the WCTN, indicated the EBP room contained recycled used gowns for staff providing care, such as wound care and incontinence care. The WCTN expressed despite being uncomfortable reusing used gowns, compliance with facility protocol was maintained. The WCTN indicated the yellow gowns were designated for day shift staff, while green gowns were for the night shift. The WCTN explained the EBP room had two gowns per each resident with #1 assigned to licensed nurses and #2 to CNAs, and gowns were used throughout the entire day shift and replaced at night. The WCTN acknowledged the risk of unseen organisms and verbalized reusing used gowns after providing direct care could have led to potential cross-contamination. On 11/01/24 11:31 AM, the Director of Environmental Services (EVS) indicated sufficient supplies of washable gowns were available if additional gowns were required during care provision, and the laundry could meet the demand. The EVS Director noted that yellow gowns were supplied daily and replaced by green gowns for the night shift. On 11/01/2024 at 2:00 PM, the Infection Preventionist (IP) indicated no policy was in place in the EBP rooms for reusing used gowns after high-contact resident care activities, such as wound treatment, turning and repositioning, incontinence care, and changing soiled linens. The Administrator explained the facility did not procure disposable gowns due to cost considerations; however, washable gowns were being utilized. A facility policy titled Isolation -Categories of Transmission-Based Precautions, revised October 2018, documented EBP expand the use of PPE and referring to the use of gowns and gloves during high contract resident care activities that provide opportunities for the transfer of MDRO's to staff hands and clothing. During these high-contact care activities, residents may indirectly transfer MDROs to one another. Residents with wounds and indwelling medical devices were at especially high risk of both acquisition of and colonization with MDRO's.

Based on observation, interview, record review, and document review, the facility failed to develop a baseline care plan for the use of an indwelling Foley catheter within 48 hours of a resident's admission for 1 of 20 sampled residents (Resident 82). This deficient practice posed potential risks, including increased likelihood of infection, catheter blockage, tissue damage, and inadequate monitoring of urinary output. Findings include: Resident 82 (R82) R82 was admitted on [DATE] and readmitted on [DATE], with the diagnoses including urinary tract infection, acute kidney infection, unstageable pressure ulcer and urinary retention. On 10/29/224 at 2:08 PM, R82 was in bed with eyes closed. R82 had Foley catheter 18 French (Fr) times (x) 5-10 milliliters (ml) water balloon. Few drops of urine observed in the urinary bag. A Physician order dated 09/26/2024, documented Foley catheter 16 FR x 10 ml water balloon for neurogenic bladder related to urine retention. The Readmit Screener dated 10/13/2024, documented R2 had indwelling/Foley catheter 16 Fr. A Nursing Progress Notes dated 10/15/2024, documented R2 Foley catheter 16 Fr draining and in place related to urinary retention/neurogenic bladder. On 10/30/2024 at 11:08 AM, a Licensed Practical Nurse (LPN) indicated the Foley catheter required an order and a baseline care plan upon resident's admission. The LPN confirmed there was no care plan in place for R82's Foley catheter. On 10/30/2024 at 1:30 PM, the Unit Manager (UM) confirmed no care plan had been formulated for R82's Foley catheter use. The UM explained a baseline care plan should have been implemented within 48 hours following R82's admission. The UM indicated the Director of Nursing (DON) was on leave and unavailable for interview, with the Assistant Director of Nursing (ADON) assuming responsibilities. On 10/31/2024 at 4:00 PM, the ADON explained the DON restricted others from handling the care plan, preferring to manage it personally. The DON was recently assigned and took on the responsibility of updating care plans. The baseline care plan supports the subsequent development of the comprehensive care plan. The ADON confirmed no care plan had been formulated for R82's Foley catheter. The ADON further explained R82 who had a urinary catheter, was flagged as a significant concern. The ADON indicated despite the resident being on hospice, the need for a care plan was affirmed to ensure adherence to person-centered care standards. The ADON indicated care plan discrepancies had previously gone unaddressed due to the DON's restrictions on plan access. A facility policy titled Care Plans-Baseline revised December 2106, documented a baseline plan of care to meet the resident's immediate needs should have been developed for each resident within forty-eight (48) hours of admission, to assure the resident's immediate care needs were met and maintained. A facility policy titled Catheter Care, Urinary, dated September 2014, documented procedures intended to prevent catheter-associated urinary tract infections. The preparation included reviewing the resident's care plan to assess any special needs of the resident.

Based on observation, interview, record review, and document review, the facility failed to develop a comprehensive care plan for: 1) fall prevention for a resident at risk for fall (Resident #56), 2) and medication self-administration (Resident #79). The deficient practice had the potential to deprive the residents for receiving necessary care to prevent health complications. Findings include: Resident #56 (R56) R56 was admitted on [DATE], with diagnoses including severe sepsis, neurocognitive disorder, history of alcoholism and drug abuse, weight loss, and cerebrovascular accident. Initial fall risk assessment dated [DATE], revealed a score of 12, indicating R56 was at risk for falls. The assessment documented if the total score was 10 or greater, the resident should be considered at a high risk for potential falls and the prevention protocol should be initiated immediately and documented on the care plan. R56 was re-assessed for fall risk on 08/11/2024, scoring 14 (high risk). The fall assessments were performed thereafter on 08/11/2024, 10/04/2024, 10/07/2024, and 10/9/2024. All of them scored 14 (High Risk) A comprehensive care plan dated 03/25/2024, lacked approaches for the prevention of falls. A nurses note dated 08/10/2024 revealed R56 was found lying face down on the floor, with a laceration on the forehead. The note did not document if fall prevention interventions were in place at the time the fall occurred. A physician order dated 08/15/20204, documented floor mattress to be in place while resident on bed. The order was obtained five days after R56 sustained the fall. On 10/31/2024 at 3:50 PM, a Nurse Manager explained when residents were admitted , a fall risk assessment was performed to identify potential factors that could increase their likelihood of falling, allowing the facility to implement preventative measures and create a personalized care plan to minimize the risk of injury from falls. The Nurse Manager acknowledged R56 was at high risk for fall and a comprehensive care plan should have been developed and implemented. 41903 Resident 79 (R79) R79 was admitted on [DATE], with diagnosis including polyneuropathy unspecified, osteoarthritis unspecified site, and abnormal posture. On 10/31/2024 at 7:05 AM, a nurse revealed R79 was to self-administer Garlic 1000 MG 1 capsule by mouth every day, which was kept in R79's room. A progress note dated 07/17/2024, documented a self-administration evaluation was completed and R79 was fully capable of administering a garlic capsule supplement. Evaluation of Resident's Ability to Self-Administer Medications dated 07/20/2024, documented resident could safely self-administer medication. A physician's order dated 07/20/2024, documented Garlic Oral Capsule 1000 MG 1 time a day, may self-administer medication, self-administration of medication evaluation completed. The medical record lacked documented evidence R79's care plan was revised to reflect self-administration of medication. On 10/31/2024 at 9:31 AM, the Assistant Director of Nursing acknowledged R79's care plan should have been updated to reflect self-administration of medication. A facility policy titled Care Plans, Comprehensive Person-Centered revised 2016, documented assessments of residents were ongoing, and care plans were to be revised as information about the residents and the resident's conditions changed.

Based on observation, interview, record review, and document review, the facility failed to ensure the resident's Foley catheter was properly assessed and the correct Foley size was inserted or clarified for 1 of 20 sampled residents (Resident 82). This deficient practice had the potential to increase the risk of discomfort or pain, or urinary tract injury and complications. Findings include: Resident 82 (R82) R82 was admitted on [DATE] and readmitted on [DATE], with the diagnoses including urinary tract infection, acute kidney infection, unstageable pressure ulcer and urinary retention. A Physician order dated 09/26/2024, documented Foley catheter 16 FR x 10 ml water balloon for neurogenic bladder related to urine retention. The Minimum Data Set, dated dated dated [DATE], documented R82 had indwelling catheter. The Readmit Screener dated 10/13/2024, documented R2 had indwelling/Foley catheter 16 Fr. A Nursing Progress Notes dated 10/15/2024, documented R2's Foley catheter 16 Fr draining and in place related to urinary retention/neurogenic bladder. On 10/29/2024 at 2:08 PM, R82 was in bed with eyes closed. R82 had Foley catheter 18 French (Fr) times (x) 5-10 milliliters (ml) water balloon with urinary droplets on the urinary bag. On 10/30/2024 at 10:45 AM, a Certified Nursing Assistant (CNA) indicated R82 was on Foley catheter since admission and under hospice care. The CNA indicated the Licensed Nurse was responsible for the assessment and insertion of the Foley catheter. The CNA confirmed R82's Foley size was French 18 x 5-10 ml water balloon. On 10/30/2024 at 11:08 AM, a Licensed Practical Nurse (LPN) verified R82's Foley catheter as an 18 Fr x 5-10 ml water balloon. The LPN confirmed the Foley catheter order specified a 16 Fr x 10 ml water balloon, but the inserted Foley was larger than ordered. The LPN indicated the order should have been followed or clarified and acknowledged a lack of documentation regarding when the Foley catheter was changed. On 10/30/2024 at 1:30 PM, the Unit Manager (UM) confirmed the Foley order had not been followed. The UM noted R82 had been hospitalized for three weeks and indicated the hospital might have changed the Foley size before the resident's return. The UM indicated an assessment should have verified the Foley in place matched the order. The UM indicated, regardless of hospice status, the facility was responsible for ensuring the order was followed or clarified. The UM also identified a communication breakdown between hospice and facility staff, explaining that hospice documentation should have been cross-checked with facility records. On 11/01/2024 at 10:26 AM, a hospice RN confirmed R82 had been admitted to hospice on 10/13/2024 with a Foley catheter inserted at the hospital. The hospice nurse indicated upon R82's readmission, the hospice admission nurse documented a Foley catheter size of 16 Fr but may have missed checking or assessing the actual catheter in place. The hospice RN explained there was no documentation R82's Foley was changed in the facility; the Foley size order should have been followed or clarified for accuracy. The hospice RN verbalized the importance of using the correct Foley catheter size to prevent leakage or trauma. A facility policy titled Catheter Care, Urinary, dated September 2014, documented procedures intended to prevent catheter-associated urinary tract infections. The preparation included reviewing the resident's care plan to assess any special needs of the resident.

Based on observation, interview, record review, and document review, the facility failed to; 1) monitor weights for a resident with prescribed weight gain (Resident #67), and 2) ensure vulnerable residents' tube feeding free water flush (FWF) orders were followed and completely delivered as ordered for 1 of 5 sampled residents receiving continue hydration via gastrostomy tube (Resident #11). The deficient practice could have led to a potential risk of dehydration, electrolyte imbalance, kidney complications, and increased susceptibility to further health issues, thereby compromising the residents' overall well-being and recovery. Findings include: 1) Weight monitoring: Resident #67 (R67) R67 was admitted on [DATE], with diagnoses including anxiety, acute psychosis, agitation, chronic obstructive pulmonary disease, hyperlipidemia, and dysphagia. R67's weight records revealed weights were obtained three times during the last 120 days as follows: 04/10/2024: 151 pounds (lbs.) 07/11/2024: 145.8 lbs. 10/24/2024: 140.4 lbs. Record revealed R67 had 7 % weight loss in 6 months. The 30 days weight changes could not be calculated due to lack of weight data in record. A Dietitian progress note dated 04/21/2024, documented R67 was prescribed weight gain to achieve a body mass index (BMI) of 23. The progress note indicated the RD would monitor weight, labs, skin, and PO intake for any further changes. A nutritional assessment dated [DATE], documented there was not an updated weight since R67 regularly refused weights. The last BMI was 20.3, slightly below the desired BMI (23). Nutritional care plan dated 08/15/2023, documented R67 had potential nutritional problem related to multiple comorbidities, including cardiac disease, respiratory, kidney and liver failure, vitamin deficiency, and mechanical altered diet due to dysphagia. The care plan did not include approaches to monitor weight and the frequency of the dietitian assessment. On 10/31/2024 at 9:30 AM, the Registered Dietitian (RD) explained the weight for a resident with prescribed weight gain should be obtained weekly as well the performance of dietary assessment. The RD acknowledged R67's weight was not monitored as per the facility's policy because R67 refused weights. The RD verbalized weight refusal should have been documented in the medical record and the care plan should have been updated with new approaches since the prescribed BMI was not achieved. The facility's policy titled Weight Assessment and Intervention dated September 2008, documented nursing staff would measure resident's weight on admission, the day after resident was admitted , and weekly for two weeks thereafter. The policy indicated if no weight concerns were identified, the weight would be obtained in a monthly basis. 2) Hydration: Resident #11 (R11) R11 was admitted on [DATE], with diagnoses including dysphagia, dementia, and seizure disorder. The resident had a gastrostomy tube (G-tube used as artificial route to provide enteral nutrition directly to the stomach). Physician's order dated 10/04/2023, documented water flushes at 30 ml/hr via G-tube, for a total of 720 ml in 24 hours. On 10/30/2024 in the morning, a review of the enteral pump 72 hours memory history revealed 1,951 ml of water were delivered over 72 hours. This amount had a discrepancy with the physician's order since 2,160 ml should had been administered (30 ml multiplied by 72 hours), indicating R11 did not receive about 209 ml of water. On 10/31/2024 in the morning, the RD confirmed R11's water flush order was not followed, and the prescribed volume was not completely delivered, with a deficit of 209 ml, impacting the daily water requirements. A facility policy titled Enteral Nutrition revised February 2008, documented adequate nutritional support through enteral nutrition was provided to residents as ordered. A facility policy revised February 2008 documented the adequate nutritional support through enteral nutrition was provided to residents as ordered. Examples of potential benefits from using a feeding tube included addressing malnutrition and dehydration, promoting wound healing, allowing residents to regain strength, and enabling a transition back to oral nutrition.

Based on observation, interview and document review, the facility failed to maintain essential kitchen equipment in good repair. The deficient practice had the potential to affect the quality and safety of the ice produced, and the lack of reliable temperature monitoring posed a risk to food safety, as it prevents accurate assessment of the freezer's ability to maintain appropriate food storage temperatures. Findings include: On 10/29/24 at 8:15 AM, an inspection was conducted in the kitchen with the kitchen manager. The following issues were identified: - Six steam table pans were observed with significant staining, exhibiting brown and white matter build-up. The discoloration and residue suggested possible water damage and inadequate cleaning practices. - The ice machine exhibited significant white mineral deposits both on its exterior and interior surfaces. The kitchen manager reported ongoing issues with the ice machine's performance, despite previous repairs. - A freezer had its manufacturer's thermometer out of service, and the internal thermometer was not functioning. The kitchen manager confirmed this observation and indicated that the thermometer was under repair and awaiting a new part. The kitchen manager verbalized despite the internal thermometer not working, the staff were checking the meal products manually to ensure they were hard frozen. The kitchen manager acknowledged the temperature of the freezer should have been monitored twice daily and documented in the log. The temperature log documented the last recorded temperatures as follows: - 10/01/2024 AM: 50.5 F - 10/03/2024 PM: 67.5 F - 10/07/2024 AM: 82 F - 10/09/2024 AM: 120 F The log noted the freezer manufacturer's thermometer was under maintenance. However, the log did not document temperatures other than the above mentioned, and there was inconsistent documentation related to the quality of the frozen goods' hardness. The facility policy titled Food Storage: Cold Foods, dated April 2018, documented an accurate thermometer would be kept in each refrigerator and freezer and a written record of daily temperature would be recorded. The facility policy titled Equipment dated September 2017, indicated all foodservice equipment would be clean, sanitary, and in proper working order.

Based on interviews, record review and document review the facility failed to ensure a dependent, non-verbal resident was not left in a wet brief for an extended period of time for 1 of 5 sampled residents (Resident 1). The deficient practice had the potential to place the resident at risk for worsening of health conditions and psychosocial harm. Findings include: Resident 1 (R1) R1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including intellectual disabilities, dementia, cognitive communication deficit, and diabetes mellitus. A Brief Interview for Mental Status (BIMS; a tool used to screen and identify the cognitive condition of a resident) on 05/14/2024 documented a score of 03, which indicated a severe cognitive impairment. A report of neglect by a staff member was received by the state agency. On 06/25/2024 at 1:00 PM, the Assistant Administrator confirmed concern regarding neglect of resident by a Certified Nursing Assistant (CNA) at the facility. The Assistant Administrator verbalized a resident had made a complaint to the social worker on 05/10/2024 regarding R1 being neglected. The Assistant Administrator indicated the social worker followed the policy and contacted the abuse coordinator and an investigation was initiated. The Assistant Administrator confirmed being the abuse coordinator and initiated an investigation with the assistance of the Director of Nursing (DON). After interviewing five residents who, according to the assistant administrator three out of five residents confirmed the initial allegation of neglect. The abuse coordinator verbalized the employee of concern was interviewed and ultimately terminated for neglect and reported to the appropriate licensing board. On 06/25/2024 at 1:30 PM the DON explained the facility expectation was for staff to make rounds at least every two hours and check on all residents during the day shift and the night shift. The decision to terminate the employee of concern was related to multiple residents with the same complaint of the employee not responding to call lights or checking on resident during shift until it was time for the next shift to arrive. During the onsite investigation on 06/25/2024, the facility correction of the past non-compliance related to the incident occurred evidenced by: On 05/10/2024, the employee of concern was suspended pending investigation and ultimately terminated and reported to the appropriate licensing board on 05/15/2024. On 05/12/2024, an in-service was initiated for all staff regarding neglect education. The DON initiated a new program of documentation for CNA staff which included: - a task list and rounding times expected. - the CNA would review at end of shift with oncoming CNA and both would sign off acknowledging the completion of specific tasks. - the unit nurse would also sign off on task form to confirm the completion of tasks by the CNA during the shift. Complaint NV00071456

Based on observation, interview, record review and document review, the facility failed to ensure a person-centered care plan was developed and implemented for a resident with limited English proficiency (LEP) for 1 of 19 sampled residents (Resident 74). The deficient practice placed the resident at risk for feeling isolated and unable to express needs impacting quality of life. Findings include: Resident 74 (R74) R74 was admitted on [DATE], with diagnoses including aphasia (a language disorder which affects a person's ability to communicate) following cerebral infarction. On 12/12/2023 at 9:18 AM, R74 laid awake in bed, television was on, and enteral feed was infusing. R74 was smiling, maintained eye contact, and attempted to mouth words but was unsuccessful. R74 was able to respond to simple questions by nodding head or moving left thumb up or down but the resident moved head from side to side removing smile when asked if R74 could understand English. There were no pictures or communication boards observed in the resident's room. A Social Services assessment dated [DATE], revealed R74 mainly understood native language which was not English. R74 did not have family and R74 communicated simple needs by gesturing, pointing, and nodding head. R74 spent most of the day in bed watching television. A communication deficit care plan initiated on 01/16/2023 revealed R74 had expressive aphasia and language barrier. The goal was for the resident to make needs known by providing translator services, communication cards and activities which match R74's communication abilities. On 12/13/2023 at 1:36 PM, the Social Services Director (SSD) confirmed there were no communication boards or picture cards in R74's room because staff did not find them to be helpful. The SSD entered the resident's room with an English picture board and placed the board in front of R74. R74 stared at the board intently with no reaction. Using a translator phone application (app) set to R74's native language, the surveyor introduced the SSD as a facility staff member who would like to assist R74. R74 turned to the SSD and smiled. Using the translator app, the surveyor explained the picture board was a communication method. R74 was asked whether the board was helpful or not. R74 responded by tapping on the phone several times which was interpreted by the SSD to mean R74 preferred the translator app which interpreted messages in written and audible form in the resident's primary language. On 12/13/2023 at 1:52 PM, the SSD reviewed R74's care plan and confirmed some of the interventions such as how activities were being provided were not person-centered and some interventions such as use of communication boards and translation (written) and interpretation (verbal) services were not being implemented. The SSD indicated utilizing the facility's language line while conducting R74's admission social services assessment on 01/16/2023 but the SSD was uncertain whether direct care staff and other disciplines utilized the language line when communicating with R74. On 12/13/2023 at 2:04 PM, the Certified Nursing Assistant (CNA) assigned to R74 indicated the communication between the resident and the CNA was limited to simple gestures such as nodding of head and raising left thumb. The CNA indicated not being familiar with the facility's language services. On 12/13/2023 at 2:09 PM, the Licensed Practical Nurse (LPN) assigned to R74 indicated identifying the resident's needs using simple questions answerable by yes or no. The LPN indicated being familiar with the facility's language line because the LPN used similar services at previous employment. The LPN indicated R74 was a good example of a resident who would benefit from the use of the language line, but the LPN acknowledged not engaging R74 in deeper conversation using the language services. On 12/14/2023 at 9:22 AM, the Activities Director indicated visiting with R74 three times a week in the resident's room where the activities director or assistant would do some reminiscing and storytelling in English. The Activities Director indicated being familiar with the facility's language services and admitted they had not utilized the language line for R74. On 12/14/2023 at 9:24 AM, the Minimum Data Set (MDS) Coordinator reviewed R74's communication care plan and verbalized some interventions were not person-centered nor realistic such as how activities were being provided to the resident. The MDS Coordinator stated some interventions such as use of the facility's language services were not being implemented and the communication boards should have been provided in the resident's native language. The Translation and/or Interpretation of Facility Services policy revised November 2020, revealed the facility's language access program would be used for residents with limited English proficiency (LEP). All LEP residents shall receive written notice in their primary language of their rights to obtain competent oral translation services free of charge. Competent oral translation of vital information shall be provided by a contracted interpreter service provider. On 12/14/2023 at 10:13 AM, the Director of Nursing (DON) confirmed R74 was not provided information regarding the facility's language services because the facility only had the document available in two languages, not including R74's primary language. The DON indicated R74's communication care plan was not person-centered nor realistic such as how activities were being provided and some interventions were not being implemented such as the use of the language line. On 12/14/23 at 10:25 AM, the DON indicated while R74 could make needs known using simple gestures, it must feel isolating to not to be able to communicate with any other person/s in native language. The Comprehensive Person-Centered Care Plan policy revised December 2016, documented a comprehensive, person-centered care plan with measurable objectives to meet the resident's physical, psychosocial, and functional needs shall be developed and implemented. Each resident's care plan would include the right to receive services included in the care plan.

Based on observation, interview, record review and document review, the facility failed to ensure a physician's order for a splint device was carried out for 1 of 19 sampled residents (Resident 46). The deficient practice placed the resident at risk for worsening contracture of the right hand. Findings include: Resident 46 (R46) R46 was admitted on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A Physician's Order dated 12/07/2023, documented to wear splint for 30 minutes two times a day and increase wear time as needed as patient tolerates. On 12/12/2023 at 9:00 AM, R46 was seated in wheelchair inside room watching television. The resident used left hand to organize personal items while the right-hand rested on the wheelchair's armrest. The resident was not wearing a splint device, nor was a splint device observed inside the resident's room. On 12/13/2023 at 8:03 AM, R46 was seated in wheelchair watching television. R46 indicated having a stroke affecting right side and therapy staff visited with R46 a week ago with a right-hand splint. R46 indicated the therapy staff member tried the splint device on R46 and R46 had refused to wear the splint device because it was too difficult for the resident to put on and remove by self plus the splint was tight and uncomfortable. The resident indicated the splint device was not in the room because therapy took the device with them and R46 emphasized no one from therapy or nursing had visited the resident to re-attempt the splint device use. On 12/13/2023 at 8:42 AM, the Director of Rehabilitation Services (DOR) explained R46 was readmitted on [DATE] following a stroke, received therapy services from 07/01/2023 to 07/19/2023 and was discharged from therapy with a goal for contracture management. The DOR retrieved a blue hand splint from a cabinet in the therapy room bearing R46's name and indicated splint devices were stored in the therapy room. On 12/13/2023 at 8:51 AM, the DOR indicated being instructed by R46's Occupational Therapist (OT) to evaluate R46 for splint wear on 12/07/2023. The DOR went to see R46, donned R46's splint which the resident refused to wear because the device did not fit properly. The DOR reported to the OT R46 had refused the splint and a re-attempt would be made within the week. The DOR indicated not having seen R46 since 12/07/2023 because the DOR assumed the OT would be the one to re-evaluate R46 for splint use. On 12/13/2023 at 9:42 AM, the OT recalled the DOR informed the OT of R46's refusal to wear the splint device but the DOR did not communicate the resident's reason for refusal was due to the splint device being ill-fitted. The OT indicated if the OT was aware the splint size was the issue, the OT would have re-evaluated R46 to obtain a better size splint or an alternative product. The OT indicated being employed at the facility on a per diem status and worked twice a week. The OT indicated a therapy staff member should have returned to R46 the following day to determine the reason for the resident's refusal, provide education regarding contractures and determine alternative options for contracture management. According to the OT, after three refusals, the physician should be contacted for alternative interventions. The medical record lacked documented evidence: 1) the resident had refused to wear the splint device due to being ill-fitted 2) the DOR communicated the reason for the resident's refusal with the OT 3) the OT or another therapy staff member re-evaluated R46 for splint use 4) the physician was notified of the resident's refusal to wear the splint device due to wrong size 5) the physician's order for splint use was transcribed into medical record and the services were provided and recorded. On 12/13/2023 at 10:01 AM, the OT explained R46's splint device was kept in the therapy room to prevent it from getting lost. The OT explained recommending R46's splint use which was confirmed by a nurse and signed by the attending physician. The OT indicated R46 was not expected to put the splint on or take the splint off on their own. The task should have been communicated to nursing services to assist R46 with application of the splint device twice daily for 30 minutes. On 12/13/2023 at 10:43 AM, the DOR confirmed there was no documentation: 1) R46 had refused to wear the splint device due to being ill-fitted 2) the DOR communicated the reason for the resident's refusal with the OT 3) the OT or another therapy staff member re-evaluated R46 for splint use 4) the physician was notified of the resident's refusal to wear the splint device due to wrong size 5) the physician's order for splint use was transcribed into medical record and the services were provided and recorded. On 12/13/2023 at 11:02 AM, the Assistant Administrator indicated therapy staff was responsible for carrying out the physician's order for R46's splint use and should have communicated the resident's plan of care with nursing services for assistance with R46's splint application. The Assistant Administrator confirmed medical records showed this was not done. On 12/13/2023 at 2:43 PM, the Director of Nursing (DON) indicated therapy staff should have communicated R46's maintenance plan with nursing which would have included the splint device to enable nursing to obtain orders related to wearing schedule, duration, cleaning of device and skin assessments. The DON confirmed physician's orders for R46's splint use on 12/07/2023 was not communicated, transcribed, and carried out and should have been. The DON indicated the splint devices were expected to be kept in resident's room not with therapy. R46's care plan for contractures initiated 08/25/2023, documented staff would encourage, supervise, and assist the resident with the use of splints and other supportive devices as recommended. The Assistive Devices and Equipment policy revised July 2017, documented use of devices was based on the resident's comprehensive assessment and documented in the resident's plan of care. The following factors would be addressed to include personal fit to ensure the device was measured to fit the resident's size. Staff would be required to demonstrate competency on the use of the device and be available to assist and supervise residents with the devices. The Specialized Rehabilitative Services policy revised December 2009, revealed the facility would initiate a maintenance program which would be implemented by nursing or restorative aides who will implement to assure the resident maintains their functional and physical status.

Based on observations, interviews, record review, and document review the facility failed to ensure a physician order for continuous use of Oxygen was followed for 1 of 19 sampled residents (Resident 53). The deficient practice had the potential for adverse outcomes for a resident requiring use of Oxygen. Findings include: Resident 53(R53) R53 was admitted on [DATE] with diagnosis of chronic respiratory failure. On 12/12/2023 at 11:50 AM, R53 verbalized receiving 4 liters per minute (LPM) of Oxygen via nasal cannula continuously. Observation indicated flow rate was set at 3 LPM on the Oxygen concentrator in room. On 12/13/2023 at 8:15 AM, the Oxygen concentrator was set at an Oxygen flow rate of 3 LPM. A certified nursing assistant (CNA) confirmed the flow rate was at 3 LPM. On 12/14/2023 at 1:15 PM, the Oxygen flow rate was 3 LPM, confirmed by CNA on the unit. A Physician Order dated 08/21/2022 documented continuous oxygen at 4 liters per minute (LPM) via nasal cannula. On 12/14/2023 in the afternoon, a Licensed Practical Nurse (LPN) indicated a physician order would need to be followed or clarified if it was not being carried out as ordered. The LPN confirmed resident the Oxygen concentrator was set at 3 LPM and should have been set at 4 LPM as the physician order dictated. The LPN explained if a resident was adjusting the flow rate without notifying the nurse it should have been identified by the nursing staff as the expectation was to check the flow rate and monitor Oxygen saturation levels at least once per shift. A care plan dated 10/31/2023 indicated to administer Oxygen based on prescriber orders with interventions to monitor flow rate and Oxygen saturation levels. On 12/15/2023 at 12:10 PM, the Director of Nursing (DON) verbalized nursing staff should follow physician orders or request clarification if order did not match what was being provided. The DON indicated nursing staff should be checking the Oxygen concentrator every shift and documenting Oxygen saturation levels daily. If the staff was monitoring daily, it should have been identified the Oxygen flow rate was below the ordered parameter and a new care plan could be developed if needed. The facility policy titled Oxygen Administration (revised October 2010) documented to verify physician order and to review the facility policy for Oxygen administration. After assessing the resident receiving Oxygen the rate of Oxygen flow, route, and rationale should be documented.

Based on observation, interview, record review and document review, the facility failed to ensure a physician's order was obtained in the administration of a medication for one unsampled resident (Resident 10). The deficient practice had the potential for the resident not receiving the physician ordered medication regimen or non-pharmacological interventions for pain management. Findings include: Resident 10 (R10) R10 was admitted on [DATE], with diagnoses including long term (current) use of opiate analgesic and other chronic pain. On 12/13/2023 at 8:31 AM, during the medication administration pass observation, R10 complained of pain to the Licensed Practical Nurse (LPN). R10 indicated having a pain scale of two when asked by the LPN (A 10-point Pain Intensity Scale where 0 = no pain, 10 = worst pain). The LPN verbalized Tylenol (Acetaminophen) for pain would have been given to the resident. On 12/13/2023 at 8:33 AM, the LPN administered Acetaminophen 325 milligram (mg) two tablets to R10. R10's medical record lacked documented evidence that a physician's order was obtained to administer Acetaminophen 325 mg two tablets for the resident's pain. On 12/13/2023 at 9:30 AM, the LPN confirmed the findings and explained the order for R10's Acetaminophen was for fever only and not for pain. The LPN indicated the order should have been clarified with the physician. On 12/13/2023 at 9:40 AM, the Director of Nursing (DON) indicated the nurses were expected to verify the physician's orders prior to giving the medications. The DON revealed all physician's orders were entered electronically and should have been in each resident's electronic medical record (EMR). On 12/15/2023 at 7:45 AM, the DON explained each resident's pain management included obtaining or clarifying the physician's orders for pharmacological and non-pharmacological interventions. The facility had a standing order for the administration of Tylenol for lower levels of pain such as mild pain. The DON acknowledged the standing order of Tylenol for pain should have been entered in R10's EMR. On 12/15/2023 at 10:16 AM, another LPN revealed the non-pharmacological interventions such as repositioning and offer snacks/fluids would have been provided to a resident who complained a pain level of two which was a mild pain. The LPN could have called the physician and obtain an order for Tylenol. The LPN confirmed a physician's order should have been obtained prior to medication administration. All orders, including standing orders, should have been entered into the resident's EMR as prescribed by the physician. The facility's policy titled Administering Medications dated April 2019, documented medications were administered in accordance with prescriber orders.

Based on observation, interview and document review, the facility failed to ensure a multi-dose Insulin pen stored in 1 of 3 medication carts inspected was dated when opened (200 Hall Medication Cart). The deficient practice had the potential for the resident to receive an expired medication. Findings include: On [DATE] at 10:14 AM, an inspection of a medication cart in 200 Hall was conducted with a Licensed Practical Nurse (LPN). An open multi-dose Insulin pen named Levemir FlexPen 100 unit/milliliter was found inside the medication cart. The medication (Insulin) was not dated nor labeled with an open date. The medication had the name of Resident 30 (a current resident). The LPN confirmed the observations and explained the medication should have been dated when opened because the medication would have expired after 28 days and had to be discarded. On [DATE] at 1:36 PM, the Director of Nursing (DON) indicated the nurses were expected to label the Insulin pen with the date when the medication was opened. The DON revealed Insulin pens expired 28 days after they were opened so they needed to be labeled with the open date. The DON provided a copy of the label of Resident 30's Levemir FlexPen 100 unit/milliliter. The label documented discard 42 days after opening. The facility's policy titled Administering Medications dated [DATE], documented the expiration/beyond use date on the medication label was checked prior to administering. When opening a multi-dose container, the date opened was recorded on the container.

Based on observation, interview, and document review the facility failed to ensure items in a refrigerator were not expired and food in the freezer was labeled and dated. The deficient practice had the potential to result in residents receiving outdated food items increasing the risk of food-borne illness. Findings include: On [DATE] at 7:48 AM, during tour of the kitchen there were individual milk cartons on a cart in the walk-in refrigerator with an expiration date of [DATE]. There were labels on the milk cartons indicating they were sent to the resident units on [DATE] and returned to kitchen. On [DATE] at 7:52 AM, the Kitchen Manager verbalized the identified milk cartons were sent to the unit on [DATE] and returned to the kitchen unopened. The Kitchen Manager indicated the milk should not have been sent to the unit or stored in the refrigerator after the expiration date and should have been discarded by the kitchen staff on [DATE]. On [DATE] at 8:06 AM, there was a clear plastic bag filled with pre-made pancakes in the freezer, and several clear plastic bags of a pre-made battered food item without a label or date. On [DATE] at 8:10 AM, the Kitchen Manager identified items as pre-made pancakes and chicken strips which were taken out of original box. The Kitchen Manager explained the process was to label and date all food items when they were delivered. The Kitchen Manager verbalized once an item was taken out of the original box they would be labeled and dated with date when item was removed from box and an expiration date. The Kitchen Manager indicated the identified items were not labeled and dated and should have been. The facility policy titled Receiving (revised ,d+[DATE]) documented safe food handling procedures for time and temperature control would be practiced in the transportation, delivery, and subsequent storage of all food items. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.

Based on observation, interview, record review and document review, the facility failed to ensure training was provided to employees regarding the facility's language line or interpretation services for 1 of 19 residents (Resident 74). The deficient practice had the potential to make residents with limited English proficiency (LEP) feel isolated and unable to express needs impacting their quality of life. Findings include: Resident 74 (R74) R74 was admitted on [DATE], with diagnoses including aphasia (a language disorder which affects a person's ability to communicate) following cerebral infarction. On 12/12/2023 at 9:18 AM, R74 was awake watching television. R74 would attempt to mouth words but unsuccessfully and was not able to respond to questions. The resident was able to smile, nod head and raise left thumb up or down. There were no pictures or communication boards observed in the room. On 12/13/2023 at 1:52 PM, the Social Services Director (SSD) indicated R74 was alert but unable to express needs to do a communication deficit compounded by a language barrier. The SSD indicated the using the facility's language line services to communicate with R74 when doing social services assessments, but the SSD was uncertain whether direct care staff utilized the language line for R74. The SSD indicated there were currently six residents in the facility who understood and spoke limited English and preferred their native language for whom the language line should be utilized by staff members. The Translation and/or Interpretation of Facility Services policy revised November 2020, documented the facility's language access program would ensure individuals with LEP shall have meaningful access to information and services provided by the facility. All LEP residents shall receive written notice in their primary language of their rights to obtain competent oral translation services free of charge. Staff shall be trained upon hire and at least annually on how to provide language access services to LEP residents. On 12/14/2023 at 11:01 AM, the Director of Nursing (DON), Director of Staff Development (DSD) and the Assistant Administrator indicated language line services had always been in place, but the facility switched vendors after the change of ownership in June 2022. The DON acknowledged R74 had not been provided written notice regarding the facility's language services because the facility only had them available in two languages, neither one was R74's native language. On 12/14/2023 at 11:06 AM, the DON indicated the use of language services was not included in the new hire orientation and no in-services or training had been provided to current staff regarding the procedure on the use of the facility's language line services or for which residents the language line was to be utilized. On 12/14/2023 at 12:00 PM, the SSD indicated being familiar with the language line procedure from a previous employer but had not received training at this facility. On 12/14/2023 at 12: 15PM, a Certified Nursing Assistant (CNA) assigned in the 200-Hall indicated not being familiar with the language line or any interpretation services. On 12/14/2023 at 12:22 PM, two LPNs in the 100-Hall indicated not being familiar with the facility's language line or interpretation services. The LPNs indicated having two residents in the 100-Hall who understood or spoke very limited English and the LPNs got by using simple questions to identify needs. On 12/14/2023 at 12:26 PM, two CNAs assigned in the 200-Hall and 300-Hall indicated not being aware the facility provided language translation services and was not familiar with the procedure. The CNA indicated there were a few residents who did not communicate in English, but the CNAs got by using simple questions to identify needs. On 12/14/23 at 10:25 AM, the DON indicated while the resident could make needs known using simple form of communication, it could be isolating to not be able to communicate with anyone in native language. The Language Line procedure document (undated), revealed professional interpreters were available in 36 languages which included sign language in video form and 240 languages in audio form.

Based on interview, record review and document review, the facility failed to ensure a resident with dementia who was assessed to be an elopement risk did not leave the facility premises unsupervised for 1 of 7 sampled residents (Resident 1). The failure to provide adequate supervision resulted in bodily injuries to the resident. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia, [CONDITION(S)] and [CONDITION(S)] with delusions, [CONDITION(S)], and major depressive disorder. R1 was under public guardianship. An Elopement/Wandering Risk data set dated [DATE], documented R1 was at risk for elopement. R1's baseline care plan dated 12/23/2020, documented R1 walked independently. R1's care plan documented R1 was at risk for elopement as evidenced by exit seeking behavior and confusion. The facility's goal was for the resident to not elope the facility and would have been monitored of their whereabouts on an ongoing basis. A Physician Order dated 12/27/2021, documented wander guard device for exit seeking. A Progress Note dated 01/20/2022, documented R1 had neurocognitive disorder with behavioral disturbances and cognitive dysfunction. R1 was hypotensive with dizziness and lightheadedness and was prescribed [MEDICATION(S)] (a medication to increase the blood pressure of a resident). A Departmental Notes dated 01/21/2022, documented R1 was confused and had an episode of elopement. R1 was last seen between 6:30 PM to 7:00 PM walking around the facility with a purse. At around 8:00 PM the nurse noticed R1 was gone. The staff members searched the building and R1 could not be found. The Director of Nursing (DON) was informed at 8:07 PM that R1 was missing, and the nurse was advised to call 911, the police arrived at 8:20 PM. At 9:40 PM, R1 was returned to the facility by the police. A head-to-toe assessment was conducted which revealed R1 sustained swollen upper lips, bruised left cheek and abrasion. A Nurses' Notes dated 01/21/2022, documented R1's wander guard was checked upon their return to the facility. The wander guard was not activating the door at the front entrance. The device was changed and replaced with a new device. A Missing Person Report dated 01/21/2022, documented the resident had dementia and had told the nurse they wanted to go home. The facility investigation report dated 01/25/2022, revealed a video footage which captured R1 leaving the facility's front door at approximately 7:00 PM alongside a plumber. The wander guard did not set-off the alarm. R1 was returned to the facility by police with injuries specifically swollen lips, bruised left cheek and abrasion. On 10/20/2022 at 8:40 AM, a Business Office Assistant conveyed the front doors were open from 8:00 AM to 5:00 PM and manned by the business office personnel. The front door was locked between 6:30 PM to 8:00 AM and attended by the nurses. On 10/20/2022 at 8:44 AM, a Licensed Practical Nurse indicated residents with dementia were monitored closely for safety reasons. On 10/20/2022 at 8:48 AM, a Registered Nurse conveyed a resident with dementia and wandering behavior could get hurt if they eloped. On 10/20/2022 at 3:15 PM, a Certified Nursing Assistant conveyed residents with dementia must be closely supervised because they could get injured or worst hit by a car if they eloped. On 10/20/2022 at 9:48 AM, the Maintenance Supervisor recounted the incident when R1 eloped from the facility on 01/21/2022. The Maintenance Supervisor reported a plumber came that day and had let R1 out without thinking R1 was a resident of the facility. The Maintenance Supervisor acknowledged the wander guard did not trigger an audible and visual alarm to alert staff members a resident had left the facility unsupervised. On 10/20/2022 at 12:31 PM, the DON recalled R1's elopement incident on 01/21/2022 at 7:00 PM and confirmed R1's wander guard did not alarm when R1 left through the front door. The DON explained the plumber may have blocked the sensor of the wander guard causing it to not trigger the wander guard system. The DON confirmed R1 returned to the facility with injuries. The facility's Abuse Prohibition Standards of Practice Policy revised 11/2017, documented the residents had the right to be free from neglect. On 10/20/2022, the facility's correction of this past non-compliance related to the incident occurred as evidenced by: -A note on the front door was posted alerting visitors to be attentive of residents who may follow them out the facility. -The facility checked the exit doors daily including the wander guard system. -The nursing staff members checked the wander guards of the residents daily with a receiver. -An observation of two residents with wander guards triggered the wander guard system and proved to be working at the time of survey. -Review of the facility's Elopement Policy corroborated the staff interviews regarding elopement. -There were no other elopement incidents reported after 01/21/2020. Facility Reported Incidents (FRI) #NV 629 and FRI #NV 638

Based on observation, interview and record review the facility failed to administer medications to the right resident for 1 of 8 sampled residents. (Resident #8) Findings include: Resident #8 Resident #8 was admitted on [DATE], hosptalized on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #9 Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. A nursing progress note dated 02/26/18, documented at approximately 12:30 PM Resident #8 was found seated in the wheelchair in his room unresponsive by staff and 911 was called. The resident's vital signs were taken and included the following: - Blood pressure: 76/38; - Heart rate: 62; - Respiration rate: 14; and - Oxygen saturation: 98 percent. The resident's pupils were pinpoint and fixed. The resident only made faces after several sternal rubs and only for a few moments. The ambulance arrived and took the resident to the hospital for evaluation. The guardian and physician were notified. A Situation, Background, Appearance, Review and Notify (SBAR) form dated 02/26/18 at 12:30 PM, documented Resident #8 had a change in condition with symptoms including unresponsiveness. The SBAR documented the resident was hard to arouse, had a decreased level of consciousness, and decreased mobility. The resident's appearance was lethargic and slightly awakened with sternal rubs. A Nursing Home to Hospital Transfer Form dated 02/26/18, documented Resident #8 was transferred to the hospital on [DATE] due to unresponsiveness. The form revealed on 02/26/18 at 12:05 PM the resident's blood pressure was 62/32 and heart rate was 58. An emergency department physician's report documented Resident #8 was brought in by emergency medical services (EMS) for altered mental status. The report revealed the resident mistakenly received the wrong medications at a nursing home at 9:00 AM. The report documented the resident received [MEDICATION NAME], and [MEDICATION NAME]. Per EMS the resident was allergic to [MEDICATION NAME]. Resident #8's clinical record lacked documented evidence the resident had physician's orders [REDACTED]. Resident #9's clinical record revealed physician's orders [REDACTED]. Resident #9's MAR indicated [REDACTED]. On 04/12/18 at 8:30 AM, a Licensed Practical Nurse (LPN) explained residents were identified prior to medication administration by verifying their picture on the computer, and checking the wrist band on the resident. The LPN explained the facility's standard of practice was to utilize the five rights of medication including right patient, right medication, right dose, right route and right time. The LPN explained if a resident was administered the wrong medications, the physician was notified immediately. The LPN indicated the Director of Nursing (DON) would be notified immediately and the resident would be assessed and monitored by taking vital signs. On 04/12/18 at 9:20 AM, another LPN was observed administering medication to a resident. The LPN verified the right patient, right medication, right dose, right route and right time. The LPN verified the right patient by looking at the resident's picture on the computer and then checking the resident, and checking the resident's wrist band. The LPN explained residents were identified prior to medication administration by verifying their picture on the computer, and checking the wrist band on the resident. The LPN explained the facility's standard of practice was to utilize the five rights of medication including right patient, right medication, right dose, right route and right time. On 04/12/18 at 9:45 AM, the Assistant Director of Nursing (ADON) explained residents were identified prior to medication administration by verifying their picture on the computer, and checking the wrist band on the resident. The ADON explained the facility's standard of practice was to utilize the five rights of medication including right patient, right medication, right dose, right route and right time. On 04/12/18 at 9:55 AM, Resident #8 indicated he was given the wrong medication. On 04/12/18 at 10:25 AM, the ADON indicated if medication was administered to the wrong resident, the resident was assessed, vital signs were completed, and the physician and DON were notified immediately. The ADON indicated if a medication incident occurred, the pharmacy would be notified immediately. The ADON recalled on 02/26/28 being called to Resident #8's room. The resident was unresponsive. The resident's vitals were checked at that time. The ADON recalled the resident was administered the wrong medications by a Registered Nurse. The ADON indicated the incorrect medications administered to the resident included psychoactive medications and [MEDICATION NAME]. The ADON indicated the resident was allergic to [MEDICATION NAME]. The ADON indicated emergency (911) was called and the resident was transported to the hospital. The ADON recalled the DON had informed her the RN mistakenly gave the resident the wrong medications. On 04/12/18 at 12:00 PM, the Director of Nursing (DON) explained residents were identified prior to medication administration by verifying their picture on the computer, and checking the wrist band on the resident. The DON explained if a resident was administered the wrong medications, the resident was assessed, vital signs were completed, and the physician and DON were notified immediately. The DON recalled Resident #8 was found unresponsive on 02/26/18 at 12:30 PM. The DON explained the resident was assessed and provided sternal rubs, and vital signs were taken. The DON explained the physician was notified immediately. The DON acknowledged the resident's blood pressure was 136/55 at 9:00 AM and 76/38 at 12:30 PM. The DON confirmed the resident's condition changed from 9:00 AM to 12:30 PM. The DON indicated the resident's condition at 12:30 PM was serious, continued to worsen, and required emergency medical attention. The DON indicated emergency (911) was called and the resident was transported to the hospital. The DON indicated a registered nurse administered the wrong medications to the Resident #8 during the morning medication administration on 02/26/18. The DON confirmed Resident #9's AM medications, including [MEDICATION NAME], and [MEDICATION NAME], were administered incorrectly to Resident #8. The DON indicated Resident #8 was allergic to [MEDICATION NAME]. The DON confirmed the Resident #8 did not have physician's orders [REDACTED]. The DON indicated the incident was investigated by the facility and the RN did not follow the five rights of medication administration. The RN informed the DON she had been monitoring Resident #8 after administering the wrong medication. The DON acknowledged the RN had not reported the incident to the physician or the DON in a timely manner, as the medication was inappropriately administered during the morning medication administration, and the DON found the resident at 12:30 PM. Resident #8's clinical record lacked documented evidence the physician and the DON were notified immediately after Resident # 9's medication was administered to the resident during the morning medication administration. A facility policy entitled Medication Administration General Guidelines dated (MONTH) 2012, documented MEDICATION ORDERS FOR [REDACTED]. Residents were identified before medication was administered using at least two resident identifiers including identification band and photograph in the medical record. A facility policy entitled Medication Error Reporting and Adverse Drug Reaction Prevention and Detection dated (MONTH) 2010, documented medication errors were considered significant if they require hospitalization . Medication orders were evaluated for known allergies [REDACTED]. These actions included prompt notification to the prescriber. Complaint #NV 250

Based on observation, interview, and document review, the facility did not ensure the environment was free of hazards. Specifically, the patio door could not be opened from the outside resulting in 1 unsampled resident being trapped outside, the hydroculator located in the therapy room was unattended, and 1 unsampled resident sustained [REDACTED].#2). Findings include: On 1/28/15 at 8:40 AM, two residents were observed in the therapy room. No staff members were present. The hydroculator was located in the corner of the room, and the lid was observed to be unsecured. The Restorative Aide was located. The Aide measured the temperature of the water in the hydroculator at 158 degrees Fahrenheit. The Physical Therapy Aide was interviewed. The Aide stated he had been in a meeting during the time of the observation, and the open hydroculator should not be accessible to residents. On 1/27/15 at 2:30 PM, a Surveyor went out to the fenced-in patio adjacent to the dining room. The door to the patio was found to be locked and the Surveyor was unable to gain access back into the building. The dining room was unoccupied. At 2:34 PM, the Dietary Manager opened the door for the Surveyor. On 1/27/15, an unsampled resident (Resident #17) was interviewed. The resident stated earlier in the day the resident had gone out to the patio and had been unable to get back into the building because the door was locked. The resident stated a staff member came and opened the door and let him in. On 1/27/15, the Maintenance Supervisor was interviewed. The Supervisor acknowledged the locked patio door could be dangerous if residents could not get back into the building. The Supervisor stated a resident could be in danger if the weather were too hot or too cold, or if a resident required oxygen and ran out. Resident #2 Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician progress notes [REDACTED]. Pt turned blue, requiring O2 (Oxygen) and a Benadryl injection, no epi (epinephrine) available in facility at the time. He has responded well, now off O2 and breathing well...Anaphalaxis (anaphylaxis), Ant bites, Pt's room changed...Monitor for further ants." A Departmental (Nursing) Note, dated 1/12/15, indicated a Licensed Practical Nurse (LPN) had been called to Resident #2's room at approximately 4:45 PM. The LPN had observed the resident to have cyanotic (blue) lips, a swollen face and tongue, redness with welts covering the resident's arms, legs and torso. Ants had been observed in the resident's bed and on the resident. The resident was given a shower and the linens had been removed from the bed. Maintenance was informed of the ants, the area was sprayed, the resident's mattress was removed from the bed and the resident was moved to another room. The SBAR (Situation Background Assessment Recommendation), dated 1/12/15, indicated the following: Situation: Ants were found in the resident's bed and welts were observed on the resident's body Background: Redness, welts, swelling to head and face was observed Assessment: RN's- allergic reaction to ant bites LPN's- allergic reaction to ant bites Request: monitor vital signs and observe, change in current orders, reported to physician via telephone call at 6:00 PM On 1/29/15 at 1:50 PM, the Maintenance/Housekeeping Manager reported being told that ants had been on Resident #2 and in the resident's room. The Manager explained once he arrived to the resident's room, one black ant was found near the head of the resident's bed on the floor. The staff had wrapped up the resident's linens and put them in a bag before Maintenance entered the resident's room. The room was deep cleaned and sprayed for ants twice on the resident's side of the room. On 1/29/15 at 1:55 PM, a Certified Nursing Assistant (CNA) reported having seen approximately ten ants in the bed with the resident and on the floor near the resident's bed on the day of the incident. An observation of Resident #2's room, on 1/29/15 at 2:05 PM, revealed the resident's bed was next to the wall, below a window. The window had a screen with a one and a half inch by half inch hole in the bottom right corner. No ants were observed in the area at the time of inspection. On 1/29/15 at 4:05 PM, the Assistant Director of Nursing (ADON) explained a nurse had reported that a CNA had said "the resident had bumps and was red on the torso." The CNA reported once the resident's covers were removed, it was believed the resident had been bitten by ants. On 1/30/15 at 3:58 PM, the Maintenance/Housekeeping Manager explained he had contacted the facility's pest control agency. The Manager stated he had sprayed the resident's room with regular household ant spray. On 1/27/15 at 9:35 AM and on 1/30/15 at 12:30 PM, an electric razor was observed plugged into the electrical outlet in the bathroom in Room 200. The razor was found sitting on top of the paper towel dispenser, on the wall adjacent to the sink, with it's electrical cord hanging down. On 1/30/15 at 12:40 PM, the Director of Nursing observed the same razor plugged in and confirmed the razor should not have been plugged in and left near the sink because it posed a hazard for the residents who used the sink.

Based on observation, interview, record review and policy review, the facility failed to ensure 1) One of 18 residents (Resident #8) was properly supervised, assessed and monitored after three falls. 2) One of 18 residents (Resident #17) was allowed to eat with his bare hands posing a safety risk with hot food and propel himself throughout the facility in bare feet. 3) The door to the supply closet remained secured. 4) The medication cart was secured. Findings include: Resident #8 1) Resident #8 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Based on the discharge summary from the acute care hospital dated 11/28/11, Resident #8 sustained a cervical facet lesion (whiplash type injury) and a laceration to head requiring sutures from the fall on 11/20/11. Resident #8 sustained a fall on 11/20/11 and was transferred to the acute care hospital emergency room . Resident #8 was transferred on 11/20/11, from the acute care hospital to the trauma unit in Las Vegas due to the nature of the injuries. Resident #8 was admitted on [DATE], to the acute care hospital in Las Vegas with [DIAGNOSES REDACTED]. The Nurse's Notes for Resident #8 documented the following: "...9/29/11 2030 (8:30 PM) Assisted back to bed c (with) ii (two) assist. Can pivot and bear wt (weight), extensive assist required. - 10/1/11-Has hard time expressing needs. Able to wheel self. call light in reach bed at lowest position. - 10/2/11 1445 (2:45 PM) Resident awake, confused, unable ans (answer) any of the simple questions. Needs help with eating, unable to grasp a cup nor hold spoon or fork. -10/3/11 1600 (4:00 PM) unable to use hands to hold or grasp anything. -10/3/11 2130 (9: assisted back to bed c two assist. Call bell in reach. -10/5/11 2000 (8:00 PM) 2 assist to bed. resident didn't bear any weight on legs. -10/26/11 11A (11:00 AM) resident continues with periodic episodes of (arrow pointing up) agitation yells and shakes fist easily agitated with other residents who are near him in dining room or common area-will attempt to stand. -10/27/11 7:00 AM In dining area conts (continues) to try to stand up in chair. Unaware of safety risk. -11/1/11 1330 (1:30 PM) observed while patient sitting on the wheelchair, resident tries to stand up. -11/3/11 2100 (9:00 PM) Resident found on floor, sitting by bed. Denies hitting head. No injuries noted. Assisted back to bed by 3 staffed. -11/5/11 0300 (3:00 AM) Also, tries to stand up from w/c (wheelchair). - 11/9/11 1900 (7:00 PM) Resident also trying to stand up. -11/15/11 0400 (4:00 AM) Resident found many times throughout noc (night?) sitting on edge of bed. o (no) attempts to get out of bed just sitting on edge. -11/17/11 2000 (8:00 PM) Resident in chair after dinner-yelling and trying to stand up. Continued to try to stand up and needed several reminders to sit. -11/19/11 1700 (5:00 PM) at 1545 (3:45 PM) resident was found laying on the floor on his back, next to his bed resident back to bed. Performed full physical assessment c no injuries noted at this time. -11/20/11 0545 (5:45 AM) Resident found on the floor beside bed unable to verbalize what happened. Bruise noted at the L (left) flank area color yellowish/green. Able to move all extremities with out (sic) difficulties. R (right side little weak. Bed in lowest position. MD (medical doctor) will be notified. -11/20/11 10:30 AM Resident found on the floor by CNA, face on the floor with moderate bleeding d (?) laceration noted, cleansed with NSS (normal sterile saline) by treatment nurse pressure applied on lacerated forehead put on clean dressing. Resident laying on left arm. ROM (range of motion) WNL (within normal limits) denies pain. MD aware sent to (name of acute care facility) ER (emergency room ) for evaluation..." A Physician order [REDACTED]. Policy review: Assessing Falls and Their Causes (revised 12/07). "...Purpose-The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. 1. Review the resident's care plan to assess for any special needs..." "...2. Defining Details of falls: a. After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred..." "...Documentation when a resident falls, the following information should be recorded in the resident's medical record: 1. The condition the resident was found (e.g., resident lying on the floor between bed and chair) 5. Completion of a fall risks assessment. 6. Appropriate interventions taken to prevent future falls..." "...Performing a Post Fall Evaluation: a. After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results of this effort. b. If the individual has no difficulty or unsteadiness, no further evaluation is needed at that time. c. If the individual has difficulty or is unsteady in performing this test, additional evaluation may be initiated as warranted." Fall Risk Assessment (revised 12/07). "...Highlights The nursing staff in conjunction with the Attending Physician, Consultant Pharmacy, therapy staff, and others, will seek to identify and document resident risk factors for falls..." Falls-Clinical Protocol (revised 4/07) "...Assessment and recognition 3. The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk..." The facility Interim Plan of Care (no date) documented Resident #8 had a history of [REDACTED]. Encouraged to use the call light. 2. To be assessed for possible contributors. 3. Alert staff. The facility Full Body Inspection form dated 9/29/11, revealed the following: "...Fall Risk Assessment-A score 0-6 indicates a low risk patient and a care plan is not indicated. A score of 7-14 indicates a moderate risk resident and care plan is indicated. A score of 15 or more indicates the patient should be enrolled in the facility Fall Prevention Program. A low score does not always indicate low risk. Any resident with a fall should be considered high risk until fall free for 180 days. As always use your nursing judgement..." Resident #8 scored a "14." as a moderate risk for falls. The subsection of the Full Body Inspection form under fall risk assessment (9/29/11) for Resident #8 the heading of cognitive status, indicated Resident #8 was mildly to moderately impaired. Resident #8's transfer ability was documented as minimum assist. The documentation for weight bearing was documented as full weight bearing. On the same form (9/29/11) under contracture status, Resident #8's mental status was documented as severely impaired. Under the heading of pressure ulcer risk assessment Resident #8's mental status was described as severely impaired. The documentation on the Full Body Inspection Form dated 9/29/11, revealed conflicting information concerning Resident #8's mental status. There was no documentation for a fall risk assessment as per policy for Resident #8's falls on 11/3/11, 11/19/11 or the two falls on 11/20/11. A Therapy Screening Form for Resident #8 dated 11/4/11, after the fall on 11/3/11, documented therapy not indicated for Occupational and Physical Therapy. There was no documentation or recommendations as to why the resident was not a candidate for therapy as facility policy, "Assessing Falls and Their Causes" indicated. Resident #8's medical record lacked documentation for identifying the cause and contributory factors leading to the resident's multiple falls as indicated in the facility policy, "Assessing Falls and Their Causes." A review of the closed medical record for Resident #8 on 3/28/12 revealed there was no comprehensive care plan for falls. The Care Plan Conference Summary dated 10/11/11, documented Resident #8 was alert and oriented times two to three. Resident #8 was able to communicate some wants and needs and the resident had no mood or behavior concerns. The medical record of Resident #8 lacked documentation of a Care Plan Conference that addressed the residents significant behavioral changes described in the nursing progress notes on 10/26/12. The Minimum Data Set ((MDS) dated [DATE], in the care area summary, identified falls as a triggered care area as a result of the antidepressant and antipsychotic medications Resident #8 received. The initial plan of care for Resident #8 dated 9/29/11 documented the resident had an alteration in ADL (activities of daily living) function as evidenced by extensive assist with bed mobility and transfers. The approaches for the plan of care included assist with bed mobility, transfers, locomotion on/off unit, eating, dressing and personal hygiene. The approaches included to keep the call light within reach and instruct the resident on use. Beginning on 10/26/11, the staff documented in the nurses notes Resident #8 began to stand up and sit up in bed without assistance. The medical record for Resident #8 lacked documentation of a comprehensive assessment (MDS) that indicated the resident had significant changes in his behavior beginning on 10/26/11. Resident #8's medical record lacked documetation of an action plan for monitoring the resident to prevent an injury when he began to get up without assistance on 10/26/11. On 3/29/12 in the morning, a second surveyor reviewed Resident #8's closed chart and was unable to locate a care plan for the prevention of falls. On 3/28/12 in the afternoon, the Director of Admissions indicated she copied the entire contents of Resident #8's closed medical record. On 3/29/12 in the morning, the MDS (Minimum Data Set) Coordinator reviewed the entire closed record for Resident #8 from 9/28/11 through 11/20/11 and was unable to locate a comprehensive care plan for the prevention of falls. On 3/29/12 in the morning, the MDS Coordinator produced the computer generated hard copy information concerning Resident #8's admission from 9/28/11 to his transfer on 11/20/11. The documentation included the CNA's ADL (activities of daily living) forms, monthly bowel and bladder reports and the MDS. The information received did not include a comprehensive care plan for falls. Resident #17 2) On 3/30/2012 at 7:45 AM, the Registered Dietician confirmed a potential for a burn if Resident #17 was served hot food and ate the food with his hands. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/29/12 during the noon meal, Resident #17 was observed sitting at a bedside table facing the wall in the common area next to the nurses' station. Resident #17 had a meal tray that consisted of sweet and sour pork and a vegetable. Resident #17 was scooping food and eating with his hands. The resident's spoon was sitting on the tray barely visible from under the plate. On 3/29/12 at 12:40 PM during an interview, the Social Worker was asked if the temperature of Resident #17's meals were assessed prior to being served. The Social Worker verbalized a care planning meeting was scheduled on Tuesday and a discussion took place about offering Resident #17 finger foods that are appropriate to eat with his hands. The Social Worker stated, "You need to speak to the Dietary Manager". On 3/29/12 at 4:53 PM during an interview, the Minimum Data Set (MDS) Coordinator verbalized, "I can't answer your question regarding the temperature of the meal tray. I don't know if the temperature is checked before giving food the residents. I have not seen anyone check the temperature of the food". On 3/29/12 at 5:10 PM during an interview, the Certified Nursing Assistant (CNA) verbalized, "I don't check the temperature of the tray before giving to Resident #17". The CNA stated, "the kitchen is supposed to check the temperature. The food comes on a hot plate with a lid". A review of Resident #17's record revealed the care plan was last updated on 3/26/12 approaches indicated: -Provide adaptive equipment for meals as needed and encourage Resident #17 to use utensils instead of his hands for meals. On 3/28/12 in the morning, Resident #17 was observed propelling himself through the facility in a wheelchair with bare feet. On 3/28/12 at 12:28 PM, Resident #17 was observed sitting in a wheelchair outside the resident dining room pushing the wheelchair back and forth with bare feet. A few moments later, the Activity Director was observed pushing Resident #17 to the common area next to the nurses' station. The resident's bare feet were dragging the floor. On 3/28/12 in the afternoon, Resident #17 was observed propelling self in a wheelchair near the resident dining area with bare feet. On 3/29/12 during the noon meal, Resident #17 was observed sitting in a wheelchair at a bedside table facing the wall in the common area next to the nurses' station with bare feet. On 3/29/12 at 4:30 PM during an interview, Employee #20 verbalized, "we tried to keep shoes on the resident but be takes them off". The employee stated when Resident #17 attended school they would hide shoes and socks in the resident's back pack and put them on him just before he would get on the bus. During an interview at 4:35 PM, the Licensed Practical Nurse (LPN) verbalized. Attempts have been made to put shoes on Resident #17 but he does not keep them on". The LPN stated, "I wish there was more for him to do since he's not in school anymore". At 4:53 PM, the MDS Coordinator verbalized, "Resident #17 does not keep socks or shoes on. We tried everything". A review of Resident #17's record revealed the care plan was last updated on 3/26/12 and there was no care plan developed with appropriate goals and interventions pertaining to the resident not wearing shoes. The facility's policy entitled, "Safety and Supervision of Residents", (Revised October 2009) under the Resident-Oriented Approach to Safety indicated: 1. Our resident-oriented approach to safety address safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for a residents, including the information obtained form the medical history, physical exam, observation of the resident, and the MDS. 3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. 4. Implementing interventions to reduce accident risks and hazards shall include the following. a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; c. providing training, as necessary; d. ensuring that interventions are implemented; and e. documenting interventions. 3) On 3/27/12 at 2:00 PM, one of the small doors leading into the nursing station was used to prop open the door to the supply room. The contents of the supply room included: containers of lotions, nail clippers, shaving cream, razors, denture cleanser, baby oil, Sani-wipe cloths, shampoo and tubes moister barrier. On 3/27/12 at 2:05 PM, a Certified Nursing Assistant (CNA) stated the door was usually closed all the time. The CNA indicated she did not know why the door was usually closed. On 3/30/12 at 7:20 AM, one of the small doors leading into the nursing station was used to prop open the door to the supply room. A Licensed Nurse (LN) stated the door to the supply room was to be closed, to keep the "supplies safe". The LN verbalized the doors to the nurse's station were to be closed when staff were not in the area. The LN stated this was to keep unwanted visitors out of the area. 4) On 3/30/12 at 3:50 PM, the medication cart was observed unlocked and unattended in the hallway by room 102. A LN stated the medication cart should have been locked. The facility's policy entitled, Storage of Medications dated,(revised 4/07), documented, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility's policy entitled, Administering Medications dated (revised 4/10), documented during the administration of medications, the medication cart was kept closed and locked when out of sight of the medication nurse or aide. #NV 341