Every finding on record at Mountain View Health and Rehabilitation

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was treated with respect and dignity when staff members discussed another resident's preferences while performing a resident's wound care for 1 of 26 sampled residents (Resident #2). This deficient practice had the potential to result in a resident experiencing feelings of diminished self-worth due to staff members engaging in a conversation about another resident, which excluded Resident #2, while providing wound care to the resident.Findings include:Resident #2Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pressure ulcer of sacral region, stage four and major depressive disorder, recurrent, unspecified.On 01/14/2026 at 1:14 PM, a surveyor observed a Registered Nurse (RN) performing a dressing change on Resident #2's pressure ulcer with the assistance of a Licensed Practical Nurse (LPN). The RN and the LPN were standing on either side of Resident #2. The RN began discussing how a type of medical equipment was beneficial for a different resident. On 01/14/2026 at 3:15 PM, the Director of Nursing (DON) and the Administrator verbalized staff should not have been speaking over the resident about a different resident. The DON verbalized the staff discussing a situation with a different resident while providing treatment for Resident #2 would not be dignified treatment of the resident. The facility policy titled Notice of Resident Rights Under Federal Law, updated 11/2016, documented the resident had the right to be treated with respect and dignity.

Based on observation, interview, clinical record review and document review, the facility failed to ensure a resident was free from misappropriation of personal property when the volume of liquid Morphine Sulfate remaining in a medication bottle did not match the facility's narcotic count in a narcotic logbook for 1 of 5 unsampled residents' records reviewed for compliance with medication storage and administration (Resident #24). This deficient practice had the potential to result in the resident not having an adequate amount of Morphine available to treat the resident's pain.Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease with late onset and low back pain, unspecified.A Physician's Order dated 03/01/2025, documented Morphine Sulfate oral solution 100 milligrams (mg)/ 5 milliliters (ml), give 0.25 ml by mouth every four hours as needed for pain or shortness of breath.On 01/15/2026 at 10:17 AM, during an inspection of the station 1C medication storage cart, a Licensed Practical Nurse (LPN) verbalized all controlled substances were counted at change of shift. Two nurses counted the total number of cards/bottles in the cart as well as the total number of tablets or amount of liquid medication remaining and verified the counts matched the narcotic logbook. If a discrepancy was identified, the nurse was to notify the Director of Nursing (DON) immediately.A bottle of liquid Morphine Sulfate with 24 ml of medication remaining in the bottle was found in the medication storage cart. The label on the bottle documented it belonged to Resident #24. A narcotic count sheet in the facility's narcotic logbook documented the bottle had 24.75 ml of Morphine Sulfate remaining.The LPN confirmed the amount of medication in the bottle was less than the quantity remaining listed on the narcotic count sheet and confirmed the LPN had completed a count of all controlled substances on the cart at the beginning of the LPN's shift.On 01/15/2026 at 10:36 AM, the DON reviewed the narcotic count sheet and confirmed the count sheet documented Resident #24's bottle of Morphine Sulfate should have had 24.75 ml remaining inside. The DON placed the bottle of Morphine Sulfate on top of the medication cart and confirmed the amount remaining in the bottle was 24 ml. The DON verbalized the DON would begin investigating the discrepancy.On 01/15/2026 at approximately 11:45 AM, the DON explained the DON had reviewed Resident #24's record and found one dose of Morphine Sulfate administered in March 2025 was not documented on the narcotic count sheet. The DON confirmed the undocumented dose accounted 0.25 ml of medication and denied the DON could find any documentation to account for the additional 0.5 ml of missing Morphine Sulfate.The DON confirmed the facility's process for narcotic inventory included documenting each administered dose on the narcotic count sheet including the amount remaining in the bottle/card and two nurses were to count the number of total cards/bottles in the cart as well as the amount of tablets/liquid remaining and ensure the counts matched. Both nurses were to sign the logbook after completing the counts and confirming there were no discrepancies. The facility did not have a formal process for oversight and frequency of auditing narcotic inventory practices amongst staff.On 01/15/2026 at 12:20 PM, the Administrator verbalized the discrepancy in Resident #24's Morphine Sulfate was being investigated for misappropriation of resident property and possible neglect.On 01/15/2026 at 1:03 PM, the Administrator verbalized when there was suspicion or an allegation of misappropriation of resident property the facility's process included implementing an immediate action to keep the resident safe, submitting an initial report to the State Agency and reporting to law enforcement if necessary. If the alleged perpetrator was a staff member, the facility would suspend the employee immediately and the Administrator would proceed with an investigation.The Administrator verbalized after interviewing the LPN, it was determined the LPN did not use correct technique when completing the counts of controlled substances in the medication cart the morning of 01/15/2026. The LPN denied the LPN placed the bottle of Morphine Sulfate on a flat surface prior to determining the volume inside. The Administrator verbalized a competency checklist used for training of nursing staff included use of the facility's narcotic logbook, however; the facility did not have training or documentation of staff's competency specific to measurement of liquid medications. The Administrator explained the narcotic logbook was recently added to the competency checklist and the Administrator was not sure if the facility had documentation of the logbook being included in the LPN's training as the LPN was hired prior to the change made to the list.The facility did not have a policy related to tracking of narcotics. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated 03/2025, documented misappropriation of resident property was the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. Examples of misappropriation of resident property and exploitation which must be reported included missing prescription medications or diversion of a resident's medications, including but not limited to, controlled substances for staff use or personal gain.Cross Reference tag F607

Based on observation, interview, clinical record review and document review, the facility failed to ensure the facility's policies related to misappropriation of resident property, abuse, and neglect were implemented timely for an allegation of misappropriation of resident property and neglect. This deficient practice resulted in delayed removal of an alleged perpetrator from resident care and access to residents' medications, placing all residents at risk for misappropriation of property and neglect.Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease with late onset and low back pain, unspecified.A Physician's Order dated 03/01/2025, documented Morphine Sulfate oral solution 100 milligrams (mg)/ 5 milliliters (ml), give 0.25 ml by mouth every four hours as needed for pain or shortness of breath.On 01/15/2026 at 10:17 AM, during an inspection of the station 1C medication storage cart, a Licensed Practical Nurse (LPN) verbalized all controlled substances were counted at change of shift. Two nurses counted the total number of cards/bottles in the cart as well as the total number of tablets or amount of liquid medication remaining and verified the counts matched the narcotic logbook. If a discrepancy was identified, the nurse was to notify the Director of Nursing (DON) immediately.A bottle of liquid Morphine Sulfate with 24 ml of medication remaining in the bottle was found in the medication storage cart. The label on the bottle documented it belonged to Resident #24. A narcotic count sheet in the facility's narcotic logbook documented the bottle had 24.75 ml of Morphine Sulfate remaining. The LPN confirmed the amount of medication in the bottle was less than the quantity remaining listed on the narcotic count sheet.On 01/15/2026 at 10:36 AM, the DON reviewed the narcotic count sheet and confirmed the count sheet documented Resident #24 should have had 24.75 ml of Morphine Sulfate remaining in the bottle. The DON placed the bottle of Morphine Sulfate on top of the medication cart and confirmed the amount remaining in the bottle was 24 ml. The DON verbalized the DON would begin investigating the discrepancy.On 01/15/2026 at approximately 11:45 AM, the DON explained the DON had reviewed Resident #24's record and found one dose of Morphine Sulfate administered in March 2025 was not documented on the narcotic count sheet. The DON confirmed the undocumented dose accounted 0.25 ml of medication and denied the DON could find any documentation accounting for the additional 0.5 ml of missing Morphine Sulfate.The DON confirmed the facility's process for narcotic inventory included documenting each administered dose on the narcotic count sheet including the amount remaining in the bottle/card and two nurses were to count the number of total cards/bottles in the cart as well as the amount of tablets/liquid remaining and ensure the counts matched. Both nurses were to sign the logbook after completing the counts and confirming there were no discrepancies.On 01/15/2026 at 11:59 AM, the LPN remained on the unit and continued to have possession of the keys to the medication storage cart, including a key to the drawer containing controlled substances.On 01/15/2026 at 12:20 PM, the Administrator verbalized the discrepancy in Resident #24's Morphine Sulfate was being investigated for misappropriation of resident property and possible neglect. The Administrator explained the facility's corporate leadership had instructed the Administrator to suspend the LPN, however; the Administrator hadn't gotten to the suspension yet.On 01/15/2026 at 12:39 PM, the LPN remained working on the unit.On 01/15/2026 at 1:03 PM, the Administrator verbalized when there was suspicion or an allegation of misappropriation of resident property the facility's process included implementing an immediate action to keep the resident safe, submitting an initial report to the State Agency and reporting to law enforcement if necessary. If the alleged perpetrator was a staff member, the facility would suspend the employee immediately and the Administrator would proceed with an investigation.The Administrator verbalized the Administrator was notified of the discrepancy in Resident #24's Morphine Sulfate just before 11:00 AM, approximately 20 minutes after the discrepancy was confirmed by the DON. The LPN was currently completing a count of the controlled substances on the medication cart with another nurse, and the LPN was being suspended. The Administrator confirmed the LPN was not suspended and removed from resident care areas immediately following the identification of the discrepancy and the DON's inability to account for the discrepancy.The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated 03/2025, documented misappropriation of resident property was the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent.The facility policy titled Abuse Investigation, updated 10/2022, documented the facility would conduct a thorough investigation of potential, suspected, and/or allegations of abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility would protect the alleged victim during and after the course of the investigation, refer to Abuse Protection policy.The facility policy titled Abuse Protection, updated 10/2022, documented the facility would protect residents from physical and psychosocial harm during and after an investigation. The facility would respond immediately to suspicion and/or allegations of abuse, neglect, and misappropriation of resident property in order to protect the alleged victim and integrity of the investigation. The facility would suspend and/or remove the alleged perpetrator from resident care areas immediately. Cross reference tag F602

Based on clinical record review, interview and document review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 26 sampled residents (Resident #74). This deficient practice had the potential to deprive the resident of a person-centered care plan and the associated interventions relative to their current health management needs.Findings include: Resident #74 Resident #74 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of dysphagia following cerebral infarction, conversion disorder with seizures or convulsions, and epilepsy, unspecified. Resident #74's weight measurements dated 01/13/2025 documented 107.0 pounds, 02/17/2025, 102.0 pounds, and 03/17/2025, 99.0 pounds. A physician progress note dated 02/02/2025, documented dysphagia following cerebral infarction, abnormal weight loss, started on Mirtazapine 7.5 milligrams (mg) at bedtime, weekly weights, monitor oral intake, registered dietitian to follow up. A Clinically Unavoidable Review and Acknowledgment for Weight Loss, signed by the provider on 03/11/2025, documented the resident's weight loss was unavoidable related to neurological disease. A physician progress note dated 03/24/2025, documented abnormal weight loss, eight-pound weight loss from January to March 2025, continue mirtazapine, followed by nutritionist. Resident #74's annual MDS assessment dated [DATE], section K0300, Weight Loss: Loss of 5 percent or more in the last month or loss of 10 percent or more in last 6 months, documented, yes, the resident was on a prescribed weight-loss regimen. On 01/15/2026 at 1:40 PM, the Director of Nursing confirmed Resident #74 had a diagnosis of dysphagia following cerebral infarction and had not been on a prescribed weight loss program. On 01/15/2026 at 1:51 PM, the MDS Licensed Practical Nurse (MDS-LPN), confirmed the coding for Resident #74's annual assessment dated [DATE], section K0300, documented the resident as having been on a prescribed weight loss program. The MDS-LPN verbalized having been unable to locate any documentation the resident had been on a prescribed weight loss program. The MDS-LPN confirmed the MDS had been coded incorrectly, and the facility followed the Resident Assessment Instrument (RAI) Manual. On 01/15/2026 at 3:14 PM, the Staff Development LPN verbalized the facility did not have a policy on MDS completion and followed the RAI manual. On 01/15/2026 at 3:23 PM, the Regional MDS Coordinator Registered Nurse verbalized having expected nurses to have reviewed and verified an MDS section for accuracy prior to signing. The Long-Term Care Facility, Resident Assessment Instrument (RAI) 3.0, User's Manual, Version 1.20.1, dated October 1, 2025, Chapter 1.3, Completion of the RAI, documented the RAI process required assessments to accurately reflect the resident's status.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a comprehensive care plan was developed related to a COVID-19 infection for 1 of 26 sampled residents (Resident #108), and 2) a resident's care plan for the care of the resident's pressure ulcer was implemented for 1 of 26 sampled residents (Resident #2). These deficient practices had the potential to result in staff being unaware of resident needs and resident needs going unmet and to result in a resident not receiving the care necessary to prevent the worsening of a chronic wound. Findings include:Resident #108 Resident #108 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of acute systolic heart failure. A physician's order, dated 01/11/2026, documented Droplet Precautions were necessary when a patient was infected with a pathogen such as influenza, pertussis, mumps, and respiratory illnesses such as those caused by coronavirus infections every shift for COVID positive for 10 days. An acute care progress note, dated 01/12/2026, documented Resident #108 tested positive for rapid antigen coronavirus on 01/11/2026. Resident #108's clinical record lacked a care plan related to a COVID-19 infection or use of Droplet Precautions. On 01/12/2026 at 9:18 AM, a sign was posted on the upper right-hand side of room [ROOM NUMBER]'s doorway. The sign documented Special Droplet/Contact Precautions. Everyone must clean their hands when entering and leaving the room, wear a face mask, wear eye protection, and wear gown and glove at the door. A Personal Protective Equipment (PPE) organizer hung on the door facing outward toward the hallway. The placard on the wall outside the room indicated the room belonged to Resident #108. On 01/14/2026 at 12:55 PM, a Licensed Practical Nurse (LPN) verbalized Droplet Precautions were used for residents with a confirmed COVID-19 infection. Staff were to don an N95 respirator, a gown, and gloves prior to entering the resident's room and doff the PPE upon exiting. The LPN verbalized Droplet Precautions were used to prevent the spread of viruses and keep a virus contained. Resident #108 tested positive for COVID-19 and was on Droplet Precautions. On 01/15/2026 at 1:27 PM, the Director of Nursing (DON) verbalized care plans guided resident care in all areas. Care plans were to be reviewed and updated continuously by facility management and nursing staff. New interventions should immediately be documented on the resident's care plan. The DON would expect to see a care plan related to COVID-19 if the resident or the resident's roommate was exposed to COVID-19. The DON explained two residents on the 200's unit of the facility tested positive for COVID-19, including Resident #108. The DON verbalized Resident #108 should have had a care plan related to the COVID-19 infection and the use of Droplet Precautions but did not. The facility policy titled, Nursing Personnel Education and Training, dated 11/2016, documented in the absence of company policy or procedure the facility utilized the [NAME] manual as a supplemental resource. Cross Reference with Tag F880. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pressure ulcer of sacral region, stage four and major depressive disorder, recurrent, unspecified On 01/12/2026 at 10:41 AM, the resident verbalized the resident had a wound. A Skin Evaluation, dated 01/09/2026, documented the resident had a stage IV pressure ulcer on the resident's coccyx. The wound measurements were 0.9 centimeters (cm) in length, 0.7 cm in width, and had a depth of 0.5 cm. A Physician's Order and the Treatment Administration Record (TAR) for Resident #2 documented the following: Cleanse coccyx pressure ulcer with wound cleanser, pat dry. Skin prep to peri-wound. Place iodoform packing strip into wound bed until lightly packed. Cover with dry dressing. Every other day shift. The start date for the order was 11/29/2025. The January 2026 TAR documented the wound care should have been completed on Monday 01/12/2026. The wound care was not documented as completed on 01/12/2026. A care plan, revised on 12/02/2025, documented the resident had a chronic stage IV coccyx wound and was at risk for further skin breakdown and impairment. Treatment would be completed as ordered. On 01/14/2026 at 11:50 AM, the Resident Care Manager (RCM) verbalized the resident's pressure ulcer dressing should have been changed on Monday, but the resident's record indicated the dressing had not been changed as ordered on Monday. On 01/14/2026 at 3:14 PM, the DON verbalized wound care would be documented on the Treatment Administration Record and confirmed the wound care ordered to be completed for Resident #2's pressure ulcer on 01/12/2026, was not documented anywhere in the resident's clinical record. The facility's Standard of Practice titled Lippincott Nursing Procedures, Ninth Edition, copyright 2023, documented the nursing care plan would serve as a database for conferring with the practitioner, other members of the health care team, and documenting resident care. Documentation of the resident's progress (or lack of it) was required by regulatory agencies monitoring health care quality. Cross reference with tag F686

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was provided pressure ulcer care as ordered by the resident's provider for 1 of 26 sampled residents (Resident #2). This deficient practice had the potential to result in a resident's pressure ulcer worsening or developing an avoidable infection.Findings include:Resident #2Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pressure ulcer of sacral region, stage four and major depressive disorder, recurrent, unspecified.On 01/12/2026 at 10:41 AM, the resident verbalized the resident had a wound.A Skin Evaluation, dated 01/09/2026, documented the resident had a stage IV pressure ulcer on the resident's coccyx. The wound measurements were 0.9 centimeters (cm) in length, 0.7 cm in width, and had a depth of 0.5 cm.A Physician's Order and the Treatment Administration Record (TAR) for Resident #2 documented the following:Cleanse coccyx pressure ulcer with wound cleanser, pat dry. Skin prep to peri-wound. Place iodoform packing strip into wound bed until lightly packed. Cover with dry dressing. Every other day shift. The start date for the order was 11/29/2025.The January 2026 TAR documented the wound care should have been completed on Monday 01/12/2026. The wound care was not documented as completed on 01/12/2026.A care plan, revised on 12/02/2025, documented the resident had a chronic stage IV coccyx wound and was at risk for further skin breakdown and impairment. Treatment would be completed as ordered.On 01/14/2026 at 11:50 AM, the Resident Care Manager (RCM) verbalized the resident's pressure ulcer dressing should have been changed on Monday, but the resident's record indicated the dressing had not been changed as ordered on Monday.On 01/14/2026 at 3:14 PM, the Director of Nursing (DON) verbalized wound care would be documented on the Treatment Administration Record and confirmed the wound care ordered to be completed for Resident #2's pressure ulcer on 01/12/2026, was not documented anywhere in the resident's clinical record.The facility policy titled Skin Integrity, updated 07/2025, documented a resident with a pressure ulcer would be provided care to treat, heal, and prevent, if possible, further development of pressure ulcers.Cross reference with tag F656

Based on observation, clinical record review, interview and document review, the facility failed to ensure staff provided adequate supervision for 1 of 26 sampled residents (Resident #87) when staff failed to verify all residents were present after discovering an open window on a secured memory care unit. This deficient practice resulted in delayed identification of a resident elopement and delayed implementation of the facility's elopement response procedures, with the potential to result in psychosocial and physical harm to the resident including injury or death.Findings include:Resident #87Resident #87 was admitted to the facility on [DATE], with diagnoses including paranoid schizophrenia and unspecified psychosis not due to a substance or known physiological condition.An initial Facility Reported Incident (FRI) dated 12/03/2025, documented Resident #87 eloped from the facility.Elopement Risk Evaluations completed on 03/27/2025, 06/26/2025, 09/25/2025, and 10/03/2025 documented Resident #87 was an elopement risk due to the resident's diagnosis of schizophrenia and wandering behaviors. Resident #87's Care Plan documented behavior monitoring. Target behaviors included exit seeking/pushing on exit doors. Interventions included ensuring the resident's safety on a secured unit. A Nursing Progress Note dated 12/03/2025, documented Resident #87 eloped from the facility. An investigation was initiated, a search of the surrounding area began, the sheriff's department was notified, and the resident was located by facility staff. Upon return to the facility, the resident was assessed by two nurses with no injuries noted.On 01/12/2026 at 10:32 AM, Resident #87 was pacing in the hallway of the 300 unit, one of the facility's secured memory care units. The resident was alert, muttering to self and was not able to engage in logical conversation.On 01/14/2026 at 12:06 PM, a Licensed Practical Nurse (LPN) verbalized the LPN was working the morning Resident #87 eloped from the facility through another resident's bedroom window. The LPN recalled another resident had previously broken multiple windows on the unit and the windows were secured with a piece of plywood until the windows could be repaired. On 12/03/2025 in the morning, the LPN was notified by a Restorative Nurse Aide the plywood was missing from one of the broken windows. The last time the LPN saw Resident #87 was at approximately 6:00 AM standing near the nurses' station. Later in the morning, during breakfast, staff identified Resident #87 was not present in the dining room and began searching for the resident. When staff could not locate Resident #87 on the unit, the facility's Administrator was notified, and several staff members began searching for the resident in the area surrounding the facility.The LPN explained when the LPN was notified of the missing plywood, staff did not confirm all residents were present on the unit as the LPN assumed the plywood was removed by the resident who previously broke the windows.On 01/15/2026 at 12:43 PM, the Administrator confirmed the Administrator was familiar with Resident #87 eloping from the facility in December 2025. The Administrator recalled another resident in the secured unit had broken multiple windows and was exit-seeking prior to the elopement. The broken windows were covered with plywood pending repair. On the morning of 12/03/2025, when staff noted the plywood on the window in the resident's room was missing, staff notified the Administrator of the plywood having been removed and the resident residing in the room was present on the unit. Staff did not complete a count of all residents on the unit at the time. During breakfast on 12/03/2025, staff noted Resident #87 was not present in the dining room and began searching for the resident. The Administrator explained if an open or unsecured window or door was identified in one of the facility's secured memory care units, staff were to complete a count to ensure all residents were present. The Administrator verbalized the Administrator felt staff had normalized the exit-seeking behavior of the resident who had broken the windows, resulting in staff's failure to complete a head count when the unsecured window was discovered sometime between 7:00 AM and 8:00 AM. The Administrator confirmed staff's identification of Resident #87 being missing from the unit and response to the resident's elopement was delayed.The facility policy titled Elopement/Wandering, updated 02/2025, defined an elopement as a resident exiting the facility without staff knowledge or the resident entering an unsafe area without staff knowledge or presence. Based on the results of an elopement/exit-seeking evaluation, care plan interventions to manage wandering and/or exit seeking behaviors were initiated.The facility document titled Keeping residents safe (0.02), Elopement risk, undated, documented all staff were to make sure all doors were locked and secured after entering/exiting the memory care unit. Residents in secured units were normally wandering/exit seeking/elopement risks and looked for any opportunity to exit the unit. If any potential risk of elopement were identified such as open doors and windows, a head count was to be completed immediately for the entire facility.FRI #2683842

Based on interview, personnel record review, and document review, the facility failed to ensure 1 of 20 sampled employees had the specific competencies and skill sets necessary to care for residents' needs (Employee #15). This deficient practice had the potential to result in physical and psychosocial harm to the residents in the facility. Findings include:Employee #15 Employee #15 was hired by the facility as a Licensed Practical Nurse (LPN) on 12/03/2025. The daily staff schedules documented Employee #15 worked in the 100's unit on 01/10/2026 and 01/11/2026. On 01/15/2026 at 2:44 PM, Human Resources/Payroll (HR) verbalized newly hired nursing staff with prior experience completed a two-week orientation consisting of skills education relating both to on-the-floor and in office experience to ensure staff understood the processes for better continuity of care. A predetermined checklist was populated for all newly hired nurses, and the competencies were evaluated by a member of nursing management. HR explained Employee #15 had over ten years of nursing experience and the employee was hired as an as-needed nurse without full-time status. As-needed nurses did not always complete an orientation consistent with the two-week requirement, however, should still receive some on-the-floor and in-office experience alongside a completed competency checklist. HR verbalized competency checklists were required to be completed before the employee could be scheduled to work to ensure staff were competent and residents were taken care of. HR verbalized Employee #15's first independent shift took place on 01/10/2026 and HR observed Employee #15 working in the 100s unit without supervision on 01/10/2026 and 01/12/2026. Employee #15's competency checklist was not present in the employee's personnel record. HR reached out to the Staff Development LPN/Infection Preventionist (IP) and was informed the IP did not believe the IP possessed Employee #15's competency checklists. On 01/15/2026 at approximately 3:08 PM, HR provided six checklists and verbalized the checklist forms belonged to Employee #15. All checklists provided lacked a name or other identification indicating ownership of the documents and were signed by the IP at the bottom of the documents. The following were included:-Licensed Nursing (LN) Orientation Checklist with skills relating to abuse reporting, event reporting, alert charting, medication ordering, provider notification, the Health Insurance Portability and Accountability Act (HIPAA), Cubix, narcotic books, code blue policy, and tourniquet use.-LN Core Competency Checklist with skills relating to medication administration, enteral and parenteral nutrition and hydration, dialysis management, pain management, skin, ostomy and catheter care, restraints and bed rails, tracheostomy care and suctioning, fall and accident prevention, and infection control.-LN Supplemental Competency Checklist with skills relating to access implanted port cannula, dressing change, saline lock flush and removal, hypodermoclysis, intravenous (IV) tubing change and flush, tracheostomy care and tube feeding.-LN Competency Dressing Technique, Aseptic-LN Competency Point of Care Testing: Blood Glucose-Tube Feeding On 01/15/2026 at 3:08 PM, the IP verbalized the IP completed the competency checklists for Employee #15. The IP explained the facility required newly hired employees to write their own name, in their own handwriting, on the top of competency checklists to authenticate ownership by the employee. The IP confirmed the checklists provided lacked the name of Employee #15 and the IP was unable to verify Employee #15's competencies were evaluated. The facility policy titled, Nursing Personnel Education and Training, dated 11/2016, documented Core Competencies were completed within the first 30 days of employment. Medication administration competency was completed prior to the employee's first independent shift for licensed nursing (LN) personnel. Cross reference with Tag F842.

Based on observation, interview and document review, the facility failed to ensure 1) medications were secured in a locked medication cart and inaccessible to residents, staff and visitors when a Registered Nurse (RN) left two bottles of medication on top of a medication cart when the cart was not within sight of the RN and 2) outdated medications were removed from 1 of 4 medication carts inspected for medication storage. This deficient practice had the potential for residents, visitors, and unauthorized staff to have access to medications and outdated medications with diminished efficacy to be administered to residents.Findings include:Unsecured medicationsOn [DATE] at 8:37 AM, an RN was in the 100 hall and began preparing medications for administration to a resident. The RN placed a bottle of Sodium Bicarbonate and a bottle of Vitamin D3 on top of the medication cart.On [DATE] at 8:43 AM, the RN locked the medication cart and entered the resident's room. The medication cart was in the hallway, not within sight of the RN, and the bottles of Sodium Bicarbonate and Vitamin D3 remained on top of the cart.On [DATE] at 8:49 AM, the RN returned to the medication cart and placed the bottles in the cart. On [DATE] at 3:27 PM, the RN confirmed the bottles of Sodium Bicarbonate and Vitamin D3 were left on top of the medication cart during the morning medication administration pass, the bottles had medication remaining inside, and the medications were not within the RN's sight when the RN entered the resident's room. The RN verbalized medications were to be placed back in the cart, and the cart was to be locked when not within sight of the nurse. It was important for medications to be secured in a locked cart or medication storage room to ensure the medications weren't accidentally misplaced and other residents did not take the medications.On [DATE] at 10:55 AM, the Director of Nursing (DON) denied it would be appropriate to leave medications on top of the medication cart when the cart was not within eyesight of the nurse. The DON explained unsecured medications could be taken by other residents.The facility policy titled Medication Storage, dated 01/2025, documented medications were to be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medications were to be stored in a controlled environment including medication carts, medication rooms, medication cabinets or other suitable containers.The facility policy titled Medication Administration, General Guidelines, dated 01/2021, documented the medication cart was to be kept closed and locked when out of sight of the medication nurse. No medications were to be kept on top of the cart.Outdated medicationsOn [DATE] at 11:39 AM, during an inspection of the medication storage cart at the nurses' station on the 300 unit, a bottle of allergy relief Diphenhydramine 25 milligram (mg) tablets was found. The expiration date printed on the bottle was 12/2025. A Licensed Practical Nurse (LPN) confirmed the expiration date had passed and the medication was outdated. The LPN verbalized expired and discontinued medications were to be removed from the medication cart and placed in a cabinet designated for medication destruction in the medication storage room.On [DATE] at 10:55 AM, the DON verbalized expired and discontinued medications were to be removed from medication storage carts. It was important for staff to check expiration dates and to remove expired and discontinued medications to prevent a medication administration error.The facility policy titled Medication Storage, dated 01/2025, documented outdated, contaminated, discontinued or deteriorated medications were to be removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order existed.

Based on clinical record review, interview, and document review, the facility failed to complete a Treatment Administration Record (TAR) for the monitoring of side effects of an anticoagulant medication, the monitoring of a Foley catheter, and the monitoring of enhanced barrier precautions, for 1 of 26 sampled residents (Resident #14). This deficient practice had the potential to inaccurately reflect the prescribed monitoring of care and the associated interventions relative to the resident's current health management needs.Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including unspecified atrial fibrillation, benign prostatic hyperplasia with lower urinary tract symptoms, and other obstructive and reflux uropathy. A physician's order dated 10/01/2025, documented Apixaban oral tablet, 5 milligrams (mg), give one tablet by mouth two times a day for atrial fibrillation. Resident #14's Medication Administration Record dated January 2025, documented Apixaban oral tablet had been administered per the physician's order. A physician's order dated 10/01/2025, documented anticoagulant medication side effects monitoring, new onset: bleeding, bruising, black tarry stools, red urine, sudden severe headache, every shift. A physician's order dated 10/03/2025, documented enhanced barrier precautions for Foley catheter, every shift. A physician's order dated 10/09/2025, documented to watch for signs of infection for Foley catheter, if catheter falls out or is clogged, if urine is leaking around the catheter, if urine becomes bloody, cloudy, or smelly, fever of 100.4 or above. Watch for redness, swelling, or drainage at the insertion site. Contact provider immediately if any of the following are observed, every shift. Resident #14's TAR dated 01/10/2026, lacked documentation the monitoring of side effects of the anticoagulant medication, the monitoring of the resident's Foley catheter, and the monitoring of enhanced barrier precautions for the Foley catheter had been completed. On 01/15/2026 at 2:22 PM, the Director of Nursing (DON) confirmed Resident #14's TAR dated 01/10/2026 had not been completed by the nurse. The DON verbalized 01/10/2026 had been Resident #14's nurse's first day working alone on the floor and expected the documentation to have been completed by the nurse on the TAR. The facility policy titled, Medication Administration, updated 06/2017, documented after treatment administrations, the nurse would sign after the treatment and double check the TAR for needed signatures or initials prior to leaving their shift. Cross Reference with Tag F726

Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) staff wore appropriate Personal Protective Equipment (PPE) when entering the rooms of 2 of 14 coronavirus (COVID-19) positive residents (Residents #108 and #58) and 2) enhanced barrier precautions (EBP) were appropriately implemented and a staff member performed hand hygiene appropriately when performing wound care for 1 of 26 sampled residents (Resident #2). The deficient practice had the potential to spread infectious illnesses to vulnerable residents in the facility and result in a resident developing an infection from a staff member's lack of hand hygiene or failure to follow appropriate EBP. Findings include:Resident #108 Resident #108 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of acute systolic heart failure. A physician's order, dated 01/11/2026, documented Droplet Precautions were necessary when a patient infected with a pathogen such as influenza, pertussis, mumps, and respiratory illnesses such as those caused by coronavirus infections every shift for COVID positive for 10 days. An acute care progress note, dated 01/12/2026, documented Resident #108 tested positive for rapid antigen coronavirus on 01/11/2026. On 01/12/2026 at 9:18 AM, a sign was posted on the upper right-hand side of room [ROOM NUMBER]'s doorway. The sign documented Special Droplet/Contact Precautions. Everyone must clean their hands when entering and leaving the room, wear a face mask, wear eye protection, and wear gown and glove at the door. A PPE organizer hung on the door facing outward toward the hallway. The placard on the wall outside the room indicated the room belonged to Resident #108. On 01/14/2026 at 12:32 PM, a Licensed Practical Nurse (LPN) wearing an N95 respirator entered room [ROOM NUMBER] without donning eye protection, gown or gloves, and closed the resident's door. The LPN exited the room, walked to the nurse's station, touched the medication cart, returned to room [ROOM NUMBER] and looked at the signage at the doorway. The LPN changed the LPN's respirator. The LPN returned to the nurse's station, used sanitizer and wheeled the medication cart down the hallway. Resident #58 Resident #58 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of COVID-19. A physician's order, dated 01/07/2026, documented Droplet Precautions were necessary when a patient infected with a pathogen such as influenza, pertussis, mumps, and respiratory illnesses such as those caused by coronavirus infections every shift for 10 days. An acute care progress note, dated 01/08/2026, documented Resident #58 tested positive for COVID-19 on 01/07/2026. On 01/14/2026 at 12:48 PM, a Droplet/Contact Precautions sign was posted on the upper right-hand side of room [ROOM NUMBER]'s doorway. A PPE organizer hung on the door facing outward toward the hallway. The placard on the wall outside the room indicated the room belonged to Resident #58. On 01/14/2026 at 12:48 PM, the LPN wearing an N95 respirator entered room [ROOM NUMBER] without donning eye protection, gown or gloves. The LPN closed the door half-way, reopened the door, stood in the doorway, and grabbed a gown from the PPE organizer. The LPN did not don the gown. The LPN entered room [ROOM NUMBER] and closed the door behind the LPN. The LPN opened the door to 216 and exited the room. The LPN changed respirators. On 01/14/2026 at 12:55 PM, the LPN verbalized Droplet Precautions were used for residents with a confirmed COVID-19 infection. Staff were to don an N95 respirator, a gown, and gloves prior to entering the resident's room and doff the PPE upon exiting. The LPN verbalized Droplet Precautions were used to prevent the spread of viruses and keep a virus contained. Two residents tested positive for COVID-19 in the 200's unit including Resident #108 in room [ROOM NUMBER] and Resident #58 in room [ROOM NUMBER]. The LPN confirmed the LPN did not don PPE prior to entering either room. On 01/15/2026 at 12:14 PM, the Staff Development LPN/Infection Preventionist (IP) verbalized Droplet Precautions were a type of Transmission Based Precautions (TBP) to be implemented for a resident with a positive COVID-19 test. Droplet Precautions required staff to don a mask, gown and gloves when providing care to the resident with a COVID-19 infection. Staff were expected to don PPE prior to entering the resident's room to limit the risk of exposure and prevent a larger outbreak in the facility. The IP verbalized two residents tested positive for COVID-19 in the 200's hall, including Residents #58 and #108. The facility policy titled SARS CoV-2 (COVID-19) Skilled Nursing Facility (SNF), revised 10/2025, documented the facility followed current Center for Disease Control (CDC) guidelines to minimize exposure to the virus causing COVID-19. TBP was recommended if the resident tested positive for COVID-19. During an outbreak, healthcare personnel wore PPE in accordance with TBP for Droplet Precautions prior to entering any COVID-19 positive room. The CDC document titled Infection Control Guidance CDC SARS CoV-2, dated 06/24/2024, documented healthcare personnel who enter the room of a patient with a confirmed SARS-CoV-2 infection should adhere to standard precautions and use a particulate respirator with N95 filters or higher, gown, gloves, and eye protection. Cross Reference with Tag F656. Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pressure ulcer of sacral region, stage four and major depressive disorder, recurrent, unspecified. On 01/12/2026 at 10:41 AM, the resident verbalized the resident had a wound. A Skin Evaluation, dated 01/09/2026, documented the resident had a stage IV pressure ulcer on the resident's coccyx. The wound measurements were 0.9 centimeters (cm) in length, 0.7 cm in width, and had a depth of 0.5 cm. A Physician's Order and the Treatment Administration Record (TAR) for Resident #2 documented the following: Cleanse coccyx pressure ulcer with wound cleanser, pat dry. Skin prep to peri-wound. Place iodoform packing strip into wound bed until lightly packed. Cover with dry dressing. Every other day shift. The start date for the order was 11/29/2025. On 01/14/2026 at 1:15 PM, a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) began preparing to change the dressing to Resident #2's pressure ulcer. The RN brought a wound cart with all of the necessary wound care supplies to the hallway in front of Resident #2's door. The RN then donned gloves and then donned a gown. The RN proceeded to touch drawers of the EBP cart in the resident's room. The RN then changed gloves without performing hand hygiene before applying clean gloves. The RN then cleaned up the resident's bowel movement with disposable wipes. The RN then walked back to the table with the wound care supplies and handled the saline vials before doffing gloves and performing hand hygiene with an alcohol-based hand rub (abhr). The RN then applied clean gloves and completed the dressing change. On 01/14/2026 at 1:26 PM, the RN had doffed the gloves used during the resident's wound care but was still wearing the isolation gown. The RN then exited the resident's room to obtain additional supplies from the wound cart while wearing the isolation gown worn when providing care to Resident #2. On 01/14/2026 at 1:31 PM, the RN verbalized the RN had not donned PPE in the correct order and the RN should have donned the gown prior to donning the gloves. The RN confirmed the RN had touched the saline vials without performing hand hygiene after cleaning up the resident's bowel movement. The RN confirmed the RN had not removed the isolation gown before returning to the wound cart after completing the wound care for Resident #2. On 01/14/2026 at 3:15 PM, the Director of Nursing (DON) verbalized the correct order for donning PPE was to don a gown and then don gloves. The DON verbalized a staff member not removing a gown prior to exiting the resident room and opening the wound cart created a risk of transferring infections as the wound cart was storing wound care supplies for all residents. The Centers for Disease Control and Prevention infographic titled Sequence for Putting On PPE, accessed 01/15/2026, documented the correct sequence for putting on PPE was to put on a gown prior to donning gloves. The facility policy titled Handwashing/Hand Hygiene, updated 08/2025, documented hand hygiene was performed as soon as feasible, after hands became contaminated and frequently during the working day. Examples of situations when hand hygiene was performed, included before and after assisting a resident with personal care activities and after removing gloves. The facility policy titled Enhanced Barrier Precautions, revised 03/26/2024, documented EBP would be indicated when wound care was performed to reduce transmission of multidrug resistant organisms.

Based on interview, record review, and document review, the facility failed to ensure a staff member received screening and education on the Sars Coronavirus 2019 (COVID-19) vaccine for 1 of 1 staff sampled for COVID-19 vaccine review. This deficient practice had the potential to result in a staff member not having the opportunity to receive the vaccine or education on the risks and benefits of the vaccine.Findings include:Employee #23Employee #23 was hired as a Registered Nurse (RN) with a start date of 08/31/2023.On 01/15/2025 at 9:55 AM, the Infection Preventionist (IP) verbalized the facility did not have any documentation of education or screening provided to the RN and confirmed the RN had not been screened for eligibility to receive the COVID-19 vaccine.The IP verbalized the facility referred to the federal regulation as the facility policy for screening and educating staff on the COVID-19 vaccine.

Based on personnel record review, interview, and document review, the facility failed to ensure initial behavioral health care training, related to dementia, was completed timely for 2 of 20 sampled employees (Employee #9 and #10). This deficient practice had the potential to prevent residents with dementia care needs from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.Findings include:Employee #9Employee #9 was hired as a Certified Nursing Assistant (CNA) on 06/16/2025.Employee #9's personnel record documented initial behavioral health care training for dementia completed on 11/01/2025.Employee #10Employee #10 was hired as a Speech Language Pathologist on 06/27/2025.Employee #10's personnel record documented initial behavioral health care training for dementia completed on 10/30/2025.On 01/15/2026 at 9:50 AM, Human Resources/Payroll explained all employees, contracted employees, and agency staff were to complete behavioral health training related to dementia within the first 30 days of hire and annually thereafter. The Human Resources/Payroll confirmed Employee #9 and Employee #10 completed initial behavioral health training related to dementia more than 30 days after being hired. The facility policy titled Nursing Personnel Education and Training, published November 2016, documented Licensed Nurses and Certified Nursing Assistants. were required to complete dementia management training and Care of cognitively impaired, and behavioral health training, to address State requirements, Federal requirements, and identified core competencies within the first 30 days of employment.The facility policy titled Centers for Medicare and Medicaid Services (CMS) Hand-in-Hand Toolkit, updated July 2017, documented the CMS Hand-in-Hand Training for dementia was provided to center employees, contract staff, and routine volunteers would be completed during new employee orientation.

Based on clinical record review, document review, and interview, the facility failed to notify the on-call medical provider after a resident experienced a fall with injury, resulting in bruising to the forehead for 1 of 25 sampled residents (Resident #2). This deficient practice had the potential to result in delayed identification and treatment of serious complications, including intracranial bleeding, for a resident receiving anticoagulation therapy.Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, muscle weakness, generalized, difficulty in walking, paroxysmal atrial fibrillation, chronic combined systolic congestive and diastolic congestive heart failure, and long-term and current use of anticoagulants. Resident #2's Care Plan dated 11/11/2021 and updated 08/30/2025, documented the resident was receiving an anticoagulant related to atrial fibrillation. A progress note dated 08/03/2025 at 3:16 AM, entered by the Registered Nurse (RN), documented the resident was found in the resident's room on the floor, with purple lumps on the forehead and smears of blood on the floor. The resident was ensuring the room door was locked and fell and hit the resident's head. The resident was alert but confused and complained of soreness from the lumps on the resident's head. A head-to-toe assessment was done. The resident had a small skin tear on the left wrist, approximately one-half inch in size. Skin tape and a Band Aid were applied. Vitals were taken. The resident was helped into the wheelchair. Pain medications were given. The Executive Director (Administrator), the Resident Care Manager (RCM) on duty, the Nurse Practitioner (NP), and the Guardian were notified. Resident was to be monitored closely. A progress note dated 08/03/2025 at 10:29 AM, entered by a Licensed Practical Nurse (LPN), documented night shift had reported Resident #2 was found on the floor in the resident's room at 2:16 AM early that morning and the resident had bruising to the head and face. The LPN had noticed bruising to the resident's face when obtaining vital signs for the resident's morning medication administration. The resident was sitting up in bed with edema to left side of her face accompanied with purple-blue discoloration. The night shift reported that the resident's left wrist was sensitive to touching along with facial grimacing and winced away when staff touched the left wrist. This nurse reached out to the NP to send the resident out for an X-ray of the left wrist. This nurse requested to add the resident's shoulder to the X-ray as well and evaluation for possible concussion due to the resident not having been at usual cognition per baseline. The NP assessed the resident and decided to send the resident to the Emergency Department (ED). The resident was transferred to the ED via ambulance later that morning. A NP progress note dated 08/03/2025 at 11:53 AM, documented Resident #2 was seen after reports of an unwitnessed fall. The unwitnessed fall happened on August third at approximately 2:15 AM. The resident was found on the ground and had injury to the left head and pain in the left shoulder and wrist. The resident was placed on post fall assessments. The resident was on anticoagulation with Eliquis twice daily and had developed significant bruising to the left forehead and periorbital area. Per staff, the resident was somewhat more confused than normal and continued to have significant pain in the left arm and ribs. The resident was sent to the emergency department for further workup as the resident was high risk due to having been on blood thinning medication. This was discussed with nursing. Nursing notes reviewed and stated that the provider was contacted in the night, however it was unclear what the outcome of the conversation was. On 11/25/2025 at 3:27 PM, the Director of Nursing (DON), verbalized nurses were expected to ensure contact with the NP, as necessary, and should document these communications in a progress note. On 11/25/2025 at 3:34 PM, the DON confirmed the NP was not notified of the resident's fall and injury until the day shift staff had done so later that morning. On 11/25/2025 at 3:43 PM, the Administrator verbalized the RN was suspended for failing to ensure notification of the NP regarding Resident #2's fall. The Administrator verbalized the NP was upset the NP had not been notified sooner due to the resident having been on an anticoagulant and was considered high risk. On 11/25/2025 at 3:48 PM, the Administrator verbalized the facility could not locate a policy for physician notification related to change of condition and confirmed the Medical Director/Physician Coverage in Emergency policy dated January 2025 was in effect during the time of the incident. The facility policy titled, Fall Management and Neurological Check, updated January 2025, lacked documentation of the notification of the physician or provider post fall. The facility policy titled, Medical Director/Physician Coverage in Emergency, dated January 2025, documented the facility staff were to contact the on-call physician, if the on-call physician was not available, the facility staff were to contact the Medical Director, if the Medical Director was not available, the facility staff were to contact the Regional Director of Operations and the Regional Support Nurse for assistance. FRI 2579716

Based on personnel record review, interview and document review, the facility failed to ensure initial elder abuse prevention training was completed timely for 1 of 10 sampled employees (Employee #8). This deficient practice had the potential to place all residents at risk for abuse and neglect. Findings include:Employee #8Employee #8 was hired as a Certified Nursing Assistant on 11/01/2025.Employee #8's personnel record lacked documented evidence elder abuse prevention training was completed upon hire.On 11/25/2025 at 2:36 PM, the Administrator verbalized abuse training was to be completed within the first orientation. Staff were not permitted to work on the floor prior to the completion of abuse training. All staff were required to complete abuse training. The Administrator confirmed Employee #8 lacked timely elder abuse training.The facility policy titled Abuse Training, updated 10/2022, documented facility staff, contract staff and routine volunteers were trained on abuse prevention, reporting, and intervention upon hire, annually and periodically thereafter in accordance with state and federal guidelines and facility needs.

Based on observation, clinical record review, interview, and document review, the facility failed to ensure the safety of a resident with wandering behaviors from elopement from the facility for 1 of 16 sampled residents (Resident #13). The deficient practice had the potential for physical and psychosocial harm to the resident. Findings include: Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including memory deficit following other cerebrovascular disease, unspecified dementia, unspecified severity, with other behavioral disturbance, and cognitive communication deficit. Elopement Risk Evaluation dated 03/04/2025, documented Resident #13 had a history of wandering, had verbalized the desire to leave the facility, and was seeking out family members placing the resident at significant risk of an unsafe situation related to the resident's diagnosis of dementia with behaviors. Care Plan dated 03/06/2025, documented Resident #13 was an elopement risk, wandered aimlessly related to impaired safety awareness, and required a secured unit. A Facility Reported Incident (FRI), documented on 03/11/2025, Resident #13 was seen walking through the main entrance of the facility from the outside. The resident resided in a secured unit and was last seen by staff at approximately 3:10 PM and not seen again until approximately 3:45 PM. The resident was wearing appropriate clothes for outside weather. On 03/13/2025 at 1:00 PM, the Executive Director confirmed Resident #13 had eloped from the facility on 03/11/2025, and was unable to determine how the resident left the facility. The Executive Director confirmed Resident #13 was in a locked unit due to the resident's diagnoses and related lack of safety awareness. The facility policy titled, Elopement/Wandering, updated February 2025, documented an elopement had occurred when a resident exited the facility without staff knowledge, and residents assessed at risk for elopement residing a locked unit were to be accompanied by a staff member while outside the facility to ensure resident safety. FRI #NV00073658

Based on observation, clinical record review, interview, and document review the facility failed to protect residents from physical abuse for 2 of 28 sampled residents (Resident #72 and #104) from resident to resident abuse. Resident #104 obtained a facial fracture resulting in actual harm. Resident #72 obtained lacerations requiring eight staples resulting in actual harm. Findings include: Resident #72 Resident #72 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's disease and anxiety disorder. Diagnoses added on 10/31/2024, included laceration without foreign body of scalp, subsequent encounter, and unspecified injury of the head, subsequent encounter. A Minimum Data Set 3.0 (MDS) assessment dated [DATE], Section C (Cognition), documented a Brief Interview for Mental Status (BIMS) assessment was not conducted for Resident #72 due to the resident was rarely and/or never understood. Resident #72's cognitive skills for daily decision making was severely impaired. A Nursing Progress Note dated 10/09/2024, documented Resident #72 walked past Resident #240, cutting in between Resident #240 and a staff member. Resident #240 grabbed and spun Resident #72 around and hit Resident #72 in the face and on the body with open hand and closed fist. Resident #72's Comprehensive Care Plan, initiated on 04/02/2021, documented the resident was at risk for resident to resident altercations related to dementia with behavioral disturbances. Interventions included redirecting Resident #72 away from other residents if Resident #72 became too friendly. The Comprehensive Care Plan documented throughout Resident #72's stay at the facility, there had been multiple resident to resident incidents where Resident #72 was hit, grabbed, and shoved by other residents. Resident #240 Resident #240 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including metabolic encephalopathy, schizoaffective disorder, bipolar type, borderline personality disorder, generalized anxiety disorder, personal history of traumatic brain injury, and other symptoms and signs involving cognitive functions and awareness. A final Facility Reported Incident (FRI) submitted to the State Agency (SA) on 10/09/2024, documented on 10/09/2024, Resident #240 was standing in the hallway outside of the nutrition room and a staff member was standing across from Resident #240. Resident #72 walked between Resident #240 and the staff member. Resident #240 grabbed Resident #72, spun the resident around and hit Resident #72 multiple times on the face and body with an open hand and a closed fist. Resident #240's MDS assessment dated [DATE], Section C (Cognition), documented a BIMS score of 10, indicating the resident had moderate cognitive impairment. Section E (Behavior) documented the resident had delusions and verbal behaviors directed towards others occurred daily. Resident #240's Comprehensive Care Plan documented the following: -A care plan initiated on 01/09/2024, documented Resident #240 had an escalation in behaviors and had pushed and punched another resident on 01/24/2024, hit another resident in the face with a teddy bear on 04/02/2024, punched another resident in the arm on 04/12/2024, and pulled another resident's hair on 08/08/2024. -A care plan initiated on 01/10/2024 documented Resident #240 had the potential to be physically aggressive. On 01/09/2024, Resident #240 hit a resident on the shoulder and hit another resident in the stomach with the back of Resident #240's hand. -On 07/22/2024, Resident #240 hit a resident on the back of the resident's shoulder. -On 09/20/2024, Resident #240 pushed a resident. -On 10/03/2024, Resident #240 pushed another resident in the hallway resulting in a fall. -On 10/09/2024, Resident #240 hit a resident who walked past Resident #240 on 10/09/2024. The resident had uncontrollable behaviors, destruction of property, and refused care and medications. Resident #240's Medication Administration Record (MAR) for October 2024, documented the resident refused medications as follows: -Aripiprazole oral tablet, 15 milligrams (mg), give one time per day for mania, was documented as refused by the resident each day from 10/01/2024-10/09/2024. -Lorazepam oral concentrate 2 mg/milliliter (ml), give one ml by mouth two times a day for anxiety, documented the morning dose of the medication was refused by the resident on 10/01 and 10/03-10/09/2024. The evening dose of the medication was refused by the resident on 10/02, 10/03, and 10/05 -10/09/2024. On 11/07/2024 at 1:45 PM, a Registered Nurse (RN) recalled being present when Resident #240 hit Resident #72. The RN explained Resident #72 walked between Resident #240 and a staff member. Resident #240 began hitting Resident #72. The RN confirmed Resident #240 often refused to take medications and had increased behaviors directed towards others, including on 10/09/2024. On 11/07/2024 at 1:53 PM, a Licensed Practical Nurse (LPN), verbalized the Executive Director was the Abuse Coordinator. On 11/07/2024 at 2:24 PM, the Executive Director verbalized on 10/09/2024, Resident #240 was in a common area of the Memory Care Unit when Resident #72 walked past Resident #240. The Executive Director confirmed Resident #240 hit Resident #72 several times in the face with an open hand and a fist. On 11/07/2024 at 2:28 PM, the Executive Director confirmed Resident #240 had been escalating all day and had refused medication. The Executive Director explained Resident #240 was non-ambulatory when first admitted to the facility, but now walked all over the unit and the resident was getting more difficult to handle. FRI #NV00072412 A final FRI submitted to the SA on 10/31/2024, documented on 10/30/2024, Resident #72 was wandering the halls and attempted to enter Resident #135's room. Resident #135 grabbed Resident #72 by the shoulder and pushed the resident to the floor, resulting in a laceration to the back of Resident #72's head. Both Residents resided in the Memory Care Unit. (Resident #72) An Alert Charting Note for Resident #72, dated 10/30/2024, documented at approximately 7:35 PM, Resident #72 was in the hallway near the door of Resident #135's room. A Licensed Practical Nurse (LPN) was requested to assist with Resident #72 following an altercation between Resident #72 and Resident #135. The nurse arrived to the scene and observed Resident #72 sitting on the floor. A staff member was assisting Resident #72 to a sitting position and was holding a compress on the back of Resident #72's head. The LPN visualized excessive blood pooling onto Resident #72's neck and draining onto the resident's clothing. The resident was transported to an acute care hospital for further evaluation. A Nurse Progress note dated 10/31/2024, documented Resident #72 arrived back at the facility at 9:00 AM. The resident had eight staples on the right side of the resident's head. Resident #135 Resident #135 was admitted to the facility on [DATE], with diagnoses including paranoid personality disorder, bipolar type, generalized anxiety disorder, auditory hallucinations, and restlessness and agitation. A diagnosis of schizoaffective disorder was added on 10/04/2024. An MDS assessment dated [DATE], Section C (Cognition), documented Resident #135's BIMS score was 99, indicating the resident did not participate in the assessment. Section E (Behavior) documented the resident had delusions, and verbal behaviors directed towards others daily. Resident #135's Medication Administration Record (MAR) for October 2024, documented the resident refused medications as follows: -Doxepin hydrochloride (HCL) 25 mg capsules, give four capsules by mouth one time a day for insomnia, was documented as refused by the resident each day from 10/02 - 10/07, 10/09, 10/11-10/16, 10/18, 10/19, 10/24-10/26, 10/30, and 10/31/2024. Doxepin HCl is a tricyclic antidepressant. - Quetiapine fumarate oral tablet 200 mg, give one tablet by mouth four times a day for mood. The medication had a stop date of 10/15/2024. The medication was refused by the resident during the morning on 10/01, 10/02, 10/04-10/11, and 10/13/-10/15. The medication was refused by the resident during each afternoon on 10/02 - 10/11, and 10/13 - 10/15. The medication was refused by the resident during each evening on 10/10/01- 10/06, 10/08 - 10/11, and 10/14/2024. The medication was refused by the resident each night on 10/03 - 10/07, 10/09, and 10/11 - 10/14/2024. -Quetiapine fumarate oral tablet 200 mg, give two tablets by mouth two times a day for mood. The medication had a start date of 10/15/2024 during the evening shift. The medication was refused by the resident each day shift on 10/16. 10/17, 10/19-10/21, 10/23, and 10/27-10/30/2024. The Medication was refused by the resident each evening shift on 10/15/10/16, 10/17, 10/18, 10/19, 10/22, 10/24 - 10/27, and 10/29 - 10/31/2024. -Diazepam oral tablet, 5 mg, give one tablet by mouth three times per day for generalized anxiety disorder. The medication was refused by the resident during each day shift on 10/01, 10/02, 10/04-10/11, 10/13-10/17, and 10/19-10/30/2024. The Medication was refused by the resident during each afternoon shift on 10/03-10/11, 10/13-10/17, 10/19-10/25, and 10/27-10/30. The Medication was refused by the resident during each evening shift on 10/02 -10/07, 10/09 -10/15, 10/18, 10/19, 10/22, and 10/24-10/31/2024. Resident #135's clinical record documented the following behaviors were noted throughout the day on 10/30/2024. -Was having auditory/visual hallucinations and responded to the hallucinations by yelling, growling and making statements which could not be understood. -Was noted to have had hallucinations and was known to respond to internal stimuli and would yell out in response. -Continued to respond to auditory and internal stimuli while in the resident's room and was grunting, laughing, and yelling. -Continued to have auditory/ visual hallucinations and was laughing maniacally in the resident's own room. -Was wandering the hallways and making noises with the resident's mouth in response to auditory/visual hallucinations and was wandering into different (resident) rooms. A Social Service Follow Up Note dated 10/31/2024, documented a Social Worker (SW) met with Resident #135, observed the resident and spoke with staff. Resident #135 did not appear to remember the altercation with Resident #72. Resident #135 was agitated and yelled at the SW to get out of the resident's room before the resident messed the SW up, the sentiments were expressed using profanities and Resident #135 was growling. The SW attempted to complete a room change for Resident #135 to move to another unit. However, the resident refused to change rooms and became more agitated and using profanities verbalized the resident was not moving to another room. On 11/07/2024 at 2:37 PM, the Executive Director verbalized the altercation between Resident #72 and Resident #135 occurred when Resident #72 wandered into Resident #135's room. The Executive Director verbalized Resident #135 did not push Resident #72, as documented in the FRI and explained Resident #135 grabbed Resident #72 and threw the resident to the ground. On 11/07/2024 at 2:44 PM, the Executive Director explained nurses were expected to write behavioral notes for each adverse behavior observed. The notes were then reviewed in the facility's stand up meeting the following day, or the following Monday for observations documented during the weekend. Therefore, the Interdisciplinary Team (IDT) would not have received the information to review until the next day. The Executive Director verbalized if the facility had a system to review behavioral documentation prior to the next shift, Resident #135 could have been placed on 1:1 supervision and the altercation between Resident #135 and #72 could have been prevented. The Executive Director confirmed the altercation between Resident #135 and Resident #72 occurred on 10/30/2024, and resulted in a laceration to Resident #72's head, requiring eight staples. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, dated 12/2023, documented abuse was the willful infliction of injury resulting in physical harm, pain or mental anguish and was irrespective of any mental or physical condition. Willful meant the individual acted deliberately and did not mean the individual must have intended to inflict injury or harm. FRI #NV00072575 49557 Resident #104 Resident #104 was admitted to the facility on [DATE], with diagnoses including vascular dementia, unspecified severity, with other behavioral disturbance and other symptoms and signs involving cognitive functions following cerebrovascular disease. Resident #140 Resident #140 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, unspecified and other symptoms and signs involving cognitive functions following cerebral infarction. A FRI dated 10/15/2024, documented Resident #140 was observed hitting Resident #104. Resident #140 pushed Resident #104 to the ground and bit Resident #104's left ear. Resident #104 was evaluated in the emergency room and was found to have sustained scratches to the resident's left ear and a facial fracture. The following notes were documented in Resident #104's clinical record: -An Emergency Department (ED) Provider Note dated 10/15/2024, documented a computed tomography (CT) scan was completed on 10/15/2024, and indicated Resident #104 had an acute fracture of the anterior wall of the left maxillary [NAME]. -A Nursing Progress Note dated 10/15/2024, documented a nurse saw a resident pushing, punching and biting another resident. The residents were separated and sent to the hospital. -An Interdisciplinary Note dated 10/16/2024, documented Resident #104 was involved in an altercation with another resident. Resident #104 sustained the following injuries: bruising to the resident's left ear, scratches to the resident's face and nose, and a fracture. -A Social Services Note dated 10/17/2024, documented Resident #104 was tearful due to not understanding why the resident was uncomfortable following the incident. The resident had noted confusion and did not recall the incident. -A Psych Follow Up Note dated 10/21/2024, documented Resident #104 was attacked and beaten up by the resident's roommate. Staff reported the resident appeared more scared and withdrawn and was demonstrating regressive behaviors. -A Social Services Note dated 10/21/2024, documented Resident #104 was displaying regressive behaviors as evidenced by urinating in the resident's closet. -A Social Services Note dated 10/22/2024, documented Resident #104 was displaying regressive behaviors as evidenced by defecating on the floor. -A Social Services Note dated 10/25/2024, documented Resident #104 had new regressive behaviors as evidenced by peeing in public or in closets rather than the restroom. -A Social Services Note dated 11/05/2024, documented Resident #104 was displaying regressive behaviors as evidenced by urinating in the trashcan. On 11/04/2024 at 4:13 PM, during a telephone interview with Resident #104's guardian, the guardian recalled the guardian was notified of a resident-to-resident incident involving Resident #104. The guardian recalled Resident #104 was sent to the emergency room following the incident and was found to have a fracture. On 11/06/2024 at 12:21 PM, a Licensed Practical Nurse (LPN) verbalized the LPN was aware of a resident-to-resident incident involving Resident #104 and Resident #140. The LPN explained the LPN was not working the day of the incident however was informed Resident #140 had attacked Resident #104 and both residents were sent out of the facility. On 11/06/2024 at 12:30 PM, a CNA verbalized physical abuse included hitting a resident. If staff observed abuse or an allegation of abuse was reported to staff, staff were to separate the residents, assure the residents' safety, and report to the Abuse Coordinator. The CNA recalled the CNA worked the evening shift on the day of the resident-to-resident incident involving Resident #104 and Resident #140. The CNA verbalized Resident #140 started hitting Resident #104. Both residents were sent out of the facility. The CNA recalled Resident #104 seemed scared and was intermittently tearful after returning to the facility. On 11/07/2024 at 11:42 AM, the Executive Director explained abuse could be intentional or non-intentional and included physical and sexual abuse, neglect, involuntary seclusion and misappropriation of resident property. The Executive Director verbalized all allegations of abuse were to be reported to the Executive Director who was also the facility's Abuse Coordinator. The Executive Director verbalized the Executive Director was familiar with a resident-to-resident incident on 10/15/2024, involving Resident #104 and Resident #140. The initial altercation was unwitnessed, however staff heard the residents fighting and immediately tried to separate the residents. The Executive Director recalled Resident #104 sustained a significant injury, a facial fracture, during the incident. The Executive Director verbalized when Resident #104 returned to the facility, the Executive Director interviewed the resident who did not recall the incident however the resident's body language and demeanor appeared to the Executive Director the resident was fearful. Resident #104 had some difficulty chewing for one to two days after return to the facility and required soft foods. The Executive Director verbalized the facility would provide social services visits for emotional support and to monitor for mental anguish following an incident of abuse. The Executive Director reviewed Resident #104's clinical record and verbalized, since the incident on 10/15/2024, Resident #104 had been visited by the facility's social worker and a talk therapist from behavioral health services. The Executive Director verbalized the clinical record indicated Resident #104 had recently developed regressive behaviors including urinating in trash cans. The Executive Director explained the development of regressive behaviors after an incident of abuse could indicate psychosocial harm. The facility policy titled Abuse, Neglect, or Exploitation, updated November 2016, defined abuse as an act by an individual which injured, exploited, or jeopardized an individual's health, welfare, or safety. Examples included physically damaging or potentially damaging non-accidental acts and emotionally damaging verbal behavior. The facility document titled Notice of Resident Rights Under Federal Law, updated November 2016, documented residents had the right to be free from verbal, sexual, physical, or mental abuse. FRI #NV00072457

Based on observation, interview, and document review, the facility failed to ensure 1) a medication cart containing resident medications was secure, 2) an open multi-dose vial had the date opened and initials of the first person to use the vial written on it in 1 of 2 medication storage rooms reviewed and 3) outdated medications were removed from 3 of 3 medication carts reviewed and 1 of 2 medication storage rooms reviewed. The deficient practice could have facilitated unauthorized access to medications in the cart and had the potential for outdated/expired medications to be administered to residents. Findings include: Unsecured Medications On 11/07/2024 at 9:14 AM, the Director of Nursing Services (DNS) verbalized medication carts should be secure when not in use. On 11/07/2024 at 10:24 AM, an unattended medication cart in the 100 hall was unlocked. A resident was standing next to the unlocked medication cart. On 11/07/2024 at 10:27 AM, a Registered Nurse (RN) returned to the unsecured medication cart and confirmed the medication cart was unlocked. The RN confirmed a resident was standing next to the medication cart and could have accessed resident medications. The facility policy titled Storage of Medication, revised 01/2024, documented in order to limit access to prescription medications, only license nurses and those authorized to administer medications were allowed to access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended to by persons with authorized access. 49557 Multi-dose vial On 11/05/2024 at 10:08 AM, during a review of the station one medication storage room and in the presence of a Licensed Practical Nurse 1 (LPN), an open vial of Tubersol 5 units/0.1 milliliters (ml) was found in the medication fridge. The vial did not have the date opened or the initials of the first person to use the vial written on it. On 11/05/2024 at 10:20 AM, the Director of Nursing Services (DNS) verbalized a multi-dose vial was required to have the date opened and the initials of the staff member opening the vial written on it. The DNS confirmed the vial of Tubersol was open and lacked the date opened or initials of the first person to use it. The facility policy titled Medication Administration, Injectable Vials and Ampules, dated January 2024, documented the date opened and the initials of the first person to use the vial were to be recorded on multi-dose vials. Outdated medications On 11/05/2024 at 10:27 AM, during a review of the station two medication cart and in the presence of an LPN2, the following medications were found: -Albuterol Sulfate inhaler 90 micrograms (mcg) per actuation (act). The discard after date printed on the pharmacy label was 06/06/2024. -Albuterol Sulfate Inhaler 90 mcg/act. The discard after date printed on the pharmacy label was 01/31/2024. -Tramadol 50 milligram (mg) tablet, 56 tablets remaining in the bubble pack. The discard after date printed on the pharmacy label was 10/26/2024. The LPN2 verbalized the discard after dates printed on the pharmacy labels for the two Albuterol Sulfate inhalers and the Tramadol tablets had passed and the medications should have been removed from the medication cart. On 11/05/2024 at 10:59 AM, during a review of the station three medication storage room and in the presence of an LPN3, a tube of Diclofenac Gel one percent was found. The discard after date printed on the pharmacy label was 08/06/2024. The LPN3 confirmed the discard after date printed on the pharmacy label for the Diclofenac Gel had passed and the medication should have been removed from stock in the medication storage room. On 11/05/2024 at 11:13 AM, during a review of the station three medication cart and in the presence of an LPN3, the following medications were found: -Hyosciamine 0.125 mg. The discard after date printed on the pharmacy label was 09/28/2024. -Liquid Pain Relief (Acetaminophen) 160 mg/5 ml. The expiration date printed on the bottle was April 2024. -Geri-Tussin (Guaifenesin) 200 mg/10 ml. The expiration date printed on the bottle was October 2024. -Cetirizine, ten mg tablets. The expiration date printed on the bottle was September 2024. -Acetaminophen suppositories, 650 mg. The expiration date printed on the box was June 2024. -Bisacodyl suppositories, 10 mg. The expiration date printed on the box was April 2024. The LPN3 confirmed the discard after date and the expiration dates for the medications had passed and the medications should have been removed from the medication cart. On 11/05/2024 at 3:35 PM, during a review of the station one medication cart, and in the presence of an LPN4, an Albuterol inhaler was found. The discard after date printed on the pharmacy label was 06/18/2024. The LPN4 verbalized the LPN4 could not read the discard after date as the print was too small. On 11/05/2024 at 3:43 PM, an LPN1 viewed the Albuterol inhaler and verbalized the discard after date printed on the Albuterol inhaler's pharmacy label was 06/18/2024. The DNS explained medications were to be removed from stock in medication carts and medication storage rooms on or before the expiration/discard after date printed on the medication. The DNS verbalized the facility abided by the discard after date printed on the pharmacy label for medications delivered from the pharmacy. The facility policy titled Medication Storage, Storage of Medications, dated January 2024, documented medications were stored according to manufacturer or provider pharmacy recommendations. Outdated medications were to be immediately removed from stock and disposed of.

Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 26 opportunities and 14 medication errors. The medication error rate was 53.85%. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. On 11/07/2024 at 8:07 AM, a Licensed Practical Nurse (LPN) began preparing to administer medications to Resident #4. Among the medications prepared were the following: -Cholecalciferol (Vitamin D) 1000 units, two tablets. -Loratadine 10 milligrams (mg), one tablet. -Fish Oil 1000 mg, one capsule. -Multivitamin, one tablet. -Fluticasone 50 micrograms (mcg) per spray. -Vitamin B1 (Thiamine) 100 mg, one tablet. -Lisinopril 10 mg, one tablet. On 11/07/2024 at 8:15 AM, the LPN administered the prepared medications to Resident #4. The November 2024 Medication Administration Record (MAR) and Order Summary Report for Resident #4 documented the following: -Cholecalciferol (Vitamin D) tablet 1000 units, give two tablets by mouth one time a day for supplement. The scheduled administration time was 7:00 AM. -Loratadine tablet 10 mg, give 10 mg by mouth one time a day for allergies. The scheduled administration time was 7:00 AM. -Fish Oil capsule, give one capsule by mouth one time a day for supplement. The scheduled administration time was 7:00 AM. -Multivitamin tablet, give one tablet by mouth one time a day for supplement. The scheduled administration time was 7:00 AM. -Fluticasone Propionate Suspension 50 mcg/ actuation (act), one spray in each nostril one time a day for allergic rhinitis. The scheduled administration time was 7:00 AM. -Thiamine (Vitamin B1) tablet 100 mg, give one tablet by mouth one time a day for supplement. The scheduled administration time was 7:00 AM. -Lisinopril oral tablet 10 mg, give one tablet by mouth one time per day for hypertension. The scheduled administration time was 7:00 AM. Resident #12 Resident #12 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of allergic rhinitis, unspecified. On 11/07/2024 at 8:17 AM, the LPN administered one spray of Fluticasone Propionate 50 mcg/act into Resident #12's left nostril. Resident #12 then requested to self-administer the remainder of the medication. Resident #12 took the bottle of Fluticasone Propionate and administered two sprays into the resident's right nostril. A physician's order dated 08/03/2024, documented Flonase Allergy Relief nasal suspension 50 mcg/act (Fluticasone Propionate), one spray in both nostrils one time a day for allergies. Resident #46 Resident #46 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. On 11/07/2024 at 8:29 AM, the LPN began preparing to administer medications to Resident #46. Among the prepared medications were the following: -Baclofen 10 mg, one tablet. -Sertraline 100 mg, one tablet. -Docusate Sodium 100 mg, one capsule. -Gabapentin 100 mg, one capsule. -Quetiapine Fumarate (Seroquel) 50 mg, one tablet. On 11/07/2024 at 8:34 AM, the LPN administered the prepared medications to Resident #46. The November 2024 MAR and Order Summary Report for Resident #46 documented the following: -Baclofen oral tablet 10 mg, give one tablet by mouth three times a day for muscle spasms. The scheduled administration time was 7:00 AM. -Sertraline Hydrochloride (HCl) tablet 100 mg, give one tablet by mouth one time a day for depression. The scheduled administration time was 7:00 AM. -Docusate Sodium capsule 100 mg, give 100 mg by mouth two times a day for constipation, hold for loose stool. The scheduled administration time was 7:00 AM. -Gabapentin capsule 100 mg, give 100 mg by mouth three times a day for anxiety, hold for sedation. The scheduled administration time was 7:00 AM. -Quetiapine Fumarate (Seroquel) tablet 50 mg, give 50 mg by mouth two times a day for psychosis. The scheduled administration time was 7:00 AM. Resident #111 Resident #111 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of heart disease, unspecified. On 11/07/2024 at 8:36 AM, the LPN began preparing to administer medications to Resident #111. Among the prepared medications was two tablets of Cyanocobalamin (Vitamin B12) 500 mcg. On 11/07/2024 at 8:40 AM, the LPN administered the prepared medication to Resident #111. The November 2024 MAR and Order Summary Report for Resident #111 documented the following: -Cyanocobalamin oral tablet 1000 mcg, give one tablet by mouth one time a day for nutritional support. The scheduled administration time was 7:00 AM. On 11/07/2024 at 9:16 AM, the Director of Nursing Services (DNS) verbalized the DNS's expectation of nursing staff when administering medications to residents was to first review physician orders and ensure the nurse was administering the correct dose to the correct resident. The DNS explained medications were to be administered within one hour before and one hour after the scheduled administration time reflected on the resident's MAR. The DNS confirmed if a medication was scheduled for 7:00 AM and administered after 8:00 AM the medication was considered late. The DNS explained residents could be allowed to self-administer medications if the resident was evaluated for safety and the facility obtained a physician's order. The DNS verbalized documentation would be in the evaluations section of the resident's electronic clinical record. Resident #12's clinical record lacked documentation of a physician's order and an evaluation for safety to self-administer medications. On 11/07/2024 at 11:37 AM, the LPN verbalized medications were to be administered to residents within one hour before and one hour after the scheduled administration time on the resident's MAR. The LPN confirmed the medications administered to resident #4, #46, and #111 during the AM medication pass, with a 7:00 AM scheduled administration time, were given late. The LPN explained the LPN had been running behind during the AM medication pass. The LPN explained residents were allowed to self-administer medications only after the resident was evaluated for safety. The evaluation included assuring the resident knew what medications were prescribed to the resident, the correct dose and the correct time. The LPN denied Resident #12 had an evaluation for self-administration of medications and should not have self-administered the Fluticasone Propionate nasal spray. The LPN verbalized the resident should have received one spray in each nostril. On 11/07/2024 at 4:25 PM, the Executive Director verbalized the facility did not have a policy defining what a medication error was. The Executive Director explained medication errors included administering a medication at the wrong time and the wrong dose. The facility policy titled Medication Administration, General Guidelines, dated January 2024, documented medications were to be administered according to written orders of the prescriber. Medications were to be administered within 60 minutes of the scheduled time. Residents were allowed to self-administer medications when specifically authorized by the prescriber, the interdisciplinary team, and in accordance with procedures for self-administration. The facility policy titled Medication Administration, Self-Administration by Resident, dated January 2023, documented residents who desired to self-administer medications were permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team had determined the practice would be safe.

Based on observation, clinical record review, interview, and document review the facility failed to ensure a resident's right to self determination was respected when the facility failed to inform a new Certified Nursing Assistant (CNA) of the resident's wishes not to be disturbed for care during the night. The CNA continued to attempt to turn the resident after the resident had asked the CNA to stop, resulting in bruising to the resident's thigh for 1 of 28 sampled residents (Resident #23). Findings include: Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including other specified arthritis, unspecified site, essential primary hypertension, and chronic obstructive pulmonary disease. An initial Facility Reported Incident (FRI) submitted to the State Agency (SA) on 10/29/2024, documented Resident #23 complained of being provided rough care by a CNA on 10/26/2024. The CNA was identified, and the date of the incident was determined to be 10/27/2024. Resident #23's Comprehensive Care Plan included a care plan with a revision date of 08/19/2024 related to grooming and personal hygiene. The care plan documented the resident did not want to be awakened for rounds and would use the call light if the resident needed assistance. On 11/04/2024 at 10:42 AM, Resident #23 verbalized the resident was provided rough care by a CNA and had bruises on the resident's thigh. The distal portion of Resident #23's thigh had three oblong purple marks measuring approximately 7-8 centimeters (cm) x 1.5 cm. Adjacent to the three oblong purple marks was a round purple mark approximately 1.5 -2.0 cm in diameter. The resident explained the CNA entered the resident's room in the middle of the night, woke the resident, ripped the sheets off of the resident, and started pulling on the resident. Resident #23 verbalized the resident told the CNA to stop, but the CNA would not listen and did not stop. Resident #23 verbalized the CNA spoke very rudely to the resident and told Resident #23 the resident had to be changed, and added do you just want to get bedsores?. A Social Services note dated 10/29/2024, documented Resident #23 had made an allegation of abuse from a staff member. The incident was reported to the Executive Director and an investigation was pending. On 11/07/2024 at 2:55 PM, the Executive Director confirmed Resident #23 had correctly identified the CNA. The Executive Director explained on the night of the incident, the CNA informed the Registered Nurse (RN) Resident #23 had complained about the CNA being too rough with care. The Executive Director further explained the CNA was not informed of the resident's wishes not to be disturbed during the middle of the night unless the resident called for assistance. The facility policy titled Notice of Resident Rights Under Federal Law, updated 11/2016, documented residents had the right to a dignified existence and self-determination. Residents had the right to be treated with respect and dignity. Residents had the right to reasonable accommodation of individual needs or preferences, except where the health or safety of the resident or other residents was endangered. FRI #NV00072571

Based on observation, interview, and clinical record review, the facility failed to ensure call light system in residents' rooms and bathrooms were equipped with call cords for residents at risk for falls for 21 of 25 sampled resident (Resident #68, #128, #12, #16, #26, #46, #66, #91, #127, #60, #39, #33, #45, #94, #131, #11, #126, #52, #582, #37, and #112) and 26 unsampled residents (Resident #6, #22, #38, #41, #51, #98, #43, #80, #27, #32, #75, #105, #122, #49, #29, #71, #76, #3, #17, #40, #101, #13, #23, #106, #21, #4, #34, #19, #118, #121, #59, #83, #104, #84, #433, and #434.) Findings include: On 03/14/18 at 11:31 AM, the Director of Nursing (DON) explained a Risk for Falls Care Plan indicated a resident had not fallen yet and the button would be appropriate without the need for a cord. The DON verbalized an Actual Falls Care Plan should have been initiated separate from Risk for Falls. The DON explained it used to be facility practice to not include call lights as an intervention on care plans if they resided in the locked units. The DON did not know how the facility was currently documenting the intervention to exclude call lights. The DON verbalized resident rooms had not had a cord for [AGE] years due to an adverse event. The DON explained the cord could be used as a weapon or for injuring self. The DON explained rooms without cords on the call light button had a cord on a light switch above the resident's bed because it was up high and could not wrap around a resident in bed. The DON explained the cords attached to the resident's bed controls should be out of the resident's reach, attached to the side of the bed as opposed to across the bed. The DON confirmed the bed cords were still accessible to the residents. The DON confirmed the requirement for staff to place the bed cords in a particular location was not care planned. The DON verbalized all staff were responsible to make sure the cord was located on the side of the bed. The DON confirmed resident's in the locked unit without room and bathroom cords and residents outside the locked unit with bathrooms without cords were not assessed for the ability to safely use the cords. The DON confirmed there were residents who could have had a cord in their room in the locked unit. The DON verbalized rounding and monitoring by staff was in place for a resident to alert staff they needed assistance. The DON confirmed the rounding and monitoring was not documented. The DON verbalized she could not define a time frame required for staff to round but the staff were taught at least every two hours. The DON confirmed there were no care plans in place regarding how residents were to alert staff if they needed assistance. The DON verified six residents had fallen in the bathrooms in the last twelve months. The DON confirmed when the residents fell , they did not have access to a cord in the bathroom. The DON verbalized there was no reason for a lack of cords in the bathrooms facility wide and a concern had not been identified. The DON verbalized if a resident fell in a bathroom, they would have to alert staff verbally or make noise. On 03/19/18 at 09:13 AM, the DON and Administrator confirmed they will be working on assessments and alternate methods to communicate without a cord for residents in the locked unit as none had been established to date. Resident #104 Resident # 104 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #104's care plan for risk for falls, updated 01/22/18, documented the resident had seven falls in the past year to include a bathroom fall on 01/31/18. The interventions included encouragement to frequently use the call light for assistance. On 03/15/18 at 4:20 PM, Resident # 104 verbalized it might have been helpful to have a string on the call bell in the bathroom when she fell . The resident verbalized she no longer used the bathroom because she did not want to fall on her face. Resident #84 Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #84's care plan for risk for falls, updated 01/17/18, documented the resident had five falls since 07/13/17 to include a bathroom fall on 07/18/18. The interventions included encouragement to frequently use the call light for assistance. Resident #433 Resident #433 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #433's care plan for risk for falls, updated 01/07/18, documented the resident had six falls since 04/24/17. The interventions included encouragement to frequently use the call light for assistance. Resident #433's nurse's notes, dated 04/24/17, documented the resident had a fall in the bathroom when he attempted to toilet himself. The resident hit his head and received a small bump and scraped his elbow. Resident #434 Resident #434 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #434's nurse's notes, dated 10/17/17, documented the resident was found on the floor of the bathroom. Resident #41 Resident #41 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #41's Morse Fall Scale assessment, dated 12/08/17, documented a score of 55. The document indicated score 45 and over represented a high risk for fall. Resident #41's care plan, updated 12/08/17, documented interventions to include encouraging the resident to use the call light for assistance. On 03/12/18 at 08:40 AM, during the initial screening of the residents, it was noted the call system in the bathroom and room did not have call cord to make the light reachable for the resident. The call system control on the wall had a button to call and was not easily reachable for the resident. Fall charting document and interdisciplinary team notes, dated 11/14/17, documented the resident sustained [REDACTED]. Resident #38 Resident #38 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #38's Morse Fall Scale assessment, dated 01/22/18, documented a score of 65. The document indicated score 45 and over represented a high risk for fall. Resident #38's care plan, updated 12/02/17, revealed the interventions for reminding the resident to use the call light was scratched. The care plan indicated the resident should ask for help when needed. On 03/12/18 at 08:09 AM during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cords to make the light reachable for the resident. The call system control on the wall had a button to call and was not easy reachable for the resident. The resident verbalized there was not a call light reachable to call the nurses for assistance Fall charting documentation and interdisciplinary team notes dated 09/11/17, 11/15/17 and 01/23/18 documented the resident sustained [REDACTED]. Resident #98 Resident #98 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #98's Morse Fall Scale assessment, dated 5/30/17, documented a score of 75. The document indicated score 45 and over represented a high risk for fall. Resident #98's care plan, updated 11/20/17, documented interventions to include encouraging the resident to use the call light for assistance. On 03/12/18 at 07:55 AM, during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cords to make the light reachable for the resident. The call system control on the wall had a button to call and was not easily reachable for the resident. Resident #6 Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6's fall evaluation, dated 08/10/17, documented a score of 15. The document indicated score 13 and above represented a high risk for fall and interventions review was required. Nurse's notes, dated 12/09/17 at 12:20 PM, documented the resident sustained [REDACTED]. Resident #6's care plan for fall risk, updated 03/08/18, documented interventions to include encouraging the resident to use the call light for assistance. On 03/12/18 at 08:20 AM, during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cords to make the light reachable for the resident. The call system control on the wall had a button to call and was not easily reachable for the resident. Resident #22 Resident #22 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 03/12/18 at 07:43 AM , during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cords to make the light reachable for the resident. The call system control on the wall had a button to call and was not easy reachable for the resident. Resident #51 Resident #51 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 03/12/18 at 10:27 AM, during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cords to make the light reachable for the resident. The call system control on the wall had a button to call and was not easily reachable for the resident. The resident verbalized he had to scream for the nurses when he needed to use the restroom. The resident could not find the call light and did not know how to activate the call light system. On 2/13/18 at 07:20 AM, the Maintenance Director explained cords from the call light system were removed about [AGE] years ago due to an incident related to a resident choking with the cord. Resident #43 Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 5:00 PM, the call light was located on the middle of the wall, between Resident #43 and Resident #80's beds. The call light is a push button and did not have a chord attached. The call light could be reached by Resident #43 and could not be viewed from Resident #43's bed. A push button call light was in the restroom next to the toilet. Resident #43's care plan for [MEDICAL CONDITION] documented Resident #43 had a fall with injury from a [MEDICAL CONDITION]. Resident #43's Master Care Plan, dated 11/20/14, documented Resident #43 had a non-injury fall on 1/17/15, fell in the dining room on 9/11/17 and a fall with a laceration on 12/15/17. The intervention on the Master Care Plan documented Resident #43 was encouraged to frequently use the call light for assistance. Resident #80 Resident #80 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 5:00 PM, the call light was located on the middle of the wall, between Resident #43 and Resident #80's beds. The call light is a push button and did not have a chord attached. The call light could not be reached by Resident #80 and could not be viewed from Resident #80's bed. A push button call light was in the restroom next to the toilet. Resident #80's care plan for Self-Care Deficit, dated 7/29/17, documented Resident #80 had a limited range of motion. Resident #80 could not turn self in bed, impaired balance, inability to transfer self, feed self, toilet self, dress self, do own personal hygiene, grooming and bathe self. Resident #80 will be assisted by staff for all activities that the resident had the inability to do. Resident #80's Master Care Plan, dated 4/21/17, documented Resident #80 had a history of [REDACTED].#80 fell from a wheelchair and as a result had a skin tear on elbow on 5/10/17. On 5/13/17, Resident #80 was found by staff on the floor at the foot of the bed with no injuries. Resident #27 Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:58 PM, the call light was located on the middle of the wall, between Resident #27 and Resident #32's beds. The call light is a push button and did not have a chord attached. The call light could not be reached by Resident #27 and could not be viewed from Resident #27's bed. A push button call light was in the restroom next to the toilet. Resident #27's care plan for Falls, documented the following falls: on 8/07/15 the resident fell from a chair in the dining room, on 8/18/15 the resident tripped while walking, on 11/11/15 the resident fell while walking in the hallway, on 4/25/16 the resident had an unwitnessed non-injury fall, on 2/13/18 the resident fell , and on 03/08/18 the resident had an unwitnessed fall in the dining room and as a result had a swollen lip. Resident #32 Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:58 PM, the call light was located on the middle of the wall, between Resident #27 and Resident #32's beds. The call light is a push button and did not have a chord attached. The call light could not be reached by Resident #32 and could not be viewed from Resident #32's bed. A push button call light was in the restroom next to the toilet. Resident #32's Master Care Plan documented the resident fell out of the wheelchair on 10/09/16, fell from wheelchair on 6/28/17, fell while self-transferring from the wheelchair to the bed on 6/29/17, and fell while self-transferring from wheelchair to chair on 3/12/18. Resident #32's care plan for fall risk, documented the resident had a history of [REDACTED]. Resident #60 Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:57 PM, the call light was located on the middle of the wall, between Resident #60 and Resident #75's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach of Resident #60's bed. A push button call light was in the restroom next to the toilet. On a care plan for falls it documented Resident #60 fell and had a skin tear on 11/05/15, fell to the floor in the dining room on 11/09/15, fell from a chair in the dining room on 3/15/16, fell on [DATE] and fell on [DATE]. Resident #75 Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:57 PM, the call light was located on the middle of the wall, between Resident #60 and Resident #75's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach of Resident #75's bed. A push button call light was in the restroom next to the toilet. Resident #75's master care plan documented the resident had a history of [REDACTED]. Resident #105 Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:54 PM, the call light was located on the middle of the wall, between Resident #105's and Resident #122's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach of Resident #105's bed. A push button call light was in the restroom next to the toilet. Resident #105's master care plan, dated 2/05/16, documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. Resident #122 Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:54 PM, the call light was located on the middle of the wall, between Resident #105's and Resident #122's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach from Resident #122's bed. A push button call light was in the restroom next to the toilet. Resident #122's Master Care Plan, dated 8/04/15, documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. Resident #122 fell in the room on 7/15/17. Resident #49 Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:56 PM, the call light was located on the middle of the wall, between Resident #49's bed and a vacant bed. The call light was a push button and did not have a chord attached. The call light could not be viewed or reached from Resident #49's bed. A push button call light was in the restroom next to the toilet. Resident #49's Master Care Plan, dated 6/07/17, documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. Resident #29 Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 during the initial observation of Resident #29, there was a call light in the middle of the wall in between Resident #29's bed and Resident #71's bed. The call light was a push button and did not have a chord attached. The call light could not be reached from Resident #29's bed. A push button call light was in the restroom next to the toilet. Resident #29's Master Care Plan, dated 3/21/14, documented the resident was at risk for falls. The care plan indicated Resident #29 had an unwitnessed fall on 03/12/16, fell out of bed on 3/12/17, was found on the floor on 3/13/17, was found on the floor on 3/19/17, was found on the floor on 4/07/17, was found on the floor on 4/21/17, and was found on the floor on 9/01/17. The Master Care Plan documented staff should conduct visual checks on the resident. The care plan did not indicate the frequency of visual checks. Resident #71 Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 during the initial observation of Resident #71, there was a call light in the middle of the wall in between Resident #29's bed and Resident #71's bed. The call light was a push button and did not have a chord attached. The call light could not be reached from Resident #71's bed. A push button call light was in the restroom next to the toilet. Resident #71's care plan for fall risk, dated 2/19/16, documented the resident had a history of [REDACTED]. Resident #76 Resident #76 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:51 PM, the call light was located on the middle of the wall between Resident #76's and Resident #39's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light. A push button call light was in the restroom next to the toilet. Resident #76's Master Care Plan, dated 10/14/16, documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. The care plan indicated on 12/08/16, the resident fell to the floor from bed, on 7/28/17, the resident fell from a wheelchair, on 9/27/17, the resident fell while attempting to stand and on 10/15/17, the resident slid to the floor. Resident #39 Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:51 PM, the call light was located on the middle of the wall between Resident #76's and Resident #39's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach of Resident #76's bed. A push button call light was in the restroom next to the toilet. Resident #39's care plan for fall risks, dated 3/22/17, documented the resident was at risk for falls and had fallen 1-2 times within the past 3 months. Resident #39's Master Care Plan, dated 3/15/17, documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. The care plan documented on 3/26/17, the resident lost balance and fell , on 06/30/17 the resident slid from wheelchair, on 7/19/17 the resident was found on the floor next to bed, on 7/27/17 the resident was found on the floor, on 8/02/17, the resident was found on the floor in room, on 11/06/17 the resident fell reaching for a table and on 3/02/18 the resident fell while ambulating and had a bump on the back of head as a result. Resident #3 Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:49 PM, the call light was located on the middle of the wall between Resident #3's and Resident #17's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach of Resident #3's bed. A push button call light was in the restroom next to the toilet. Resident #3's Master Care Plan, dated 2/07/17, documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. The care plan documented Resident #3 fell on [DATE] and as a result had a skin tear. Resident #17 Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:49 PM, the call light was located on the middle of the wall between Resident #3's and Resident #17's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach of Resident #17's bed. A push button call light was in the restroom next to the toilet. Resident #17's Master Care Plan, dated 3/31/16, documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. Resident #40 Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/13/18 at 3:08 PM, the call light was located on the middle of the wall between Resident #40's bed and Resident #33's bed. The call light was a push button and did not have a chord attached. The call light was not within reach of Resident #40's bed. A push button call light was in the restroom next to the toilet. On 3/13/18 at 3:08 PM, Resident #40 explained he did not know what the button on the wall was used for. Resident #40's Master Care Plan, documented Resident #40 was at risk for falls and encouraged the resident to frequently use the call light for assistance. Resident #33 Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 3/13/18 at 3:08 PM, the call light was located on the middle of the wall between Resident #40's bed and Resident #33's bed. The call light was a push button and did not have a chord attached. The call light was not within reach of Resident #33's bed. A push button call light was in the restroom next to the toilet. Resident #33's Self-Care Deficit Care Plan, dated 4/05/16, documented the resident had limited range of motion and had the inability to turn self in bed, balance, self-transfer, feed self, toilet self, dress self, do personal hygiene, grooming, and bathe self. Resident #33's [MEDICAL CONDITION] Care Plan, dated 4/05/16, documented the resident was at risk for falls and injuries due to [MEDICAL CONDITION] activity. Resident #33's Master Care Plan, dated 9/06/16, documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. Resident #45 Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:45 PM, the call light was located on the middle of the wall between Resident #45's and Resident #101's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach of Resident #45's bed. A push button call light was in the restroom next to the toilet. On 3/12/18 at 4:45 PM, Resident #45 expressed she did not know how to call staff for help. Resident #45's Master Care Plan, dated 9/13/17, documented the resident was at risk for falls and encouraged resident to frequently use the call light for assistance. Resident #101 Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:45 PM, the call light was located on the middle of the wall between Resident #45's and Resident #101's beds. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach of Resident #101's bed. A push button call light was in the restroom next to the toilet. Resident #101's Master Care Plan documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. Resident #94 Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/12/18 at 4:38 PM, the call light was located on the middle of the wall between Resident #94's bed and a vacant bed. The call light was a push button and did not have a chord attached. There was a privacy curtain obstructing the view of the call light and the call light was not within reach of Resident #94's bed. A push button call light was in the restroom next to the toilet. Resident #94's Master Care Plan, dated 1/13/17, documented the resident was at risk for falls and encouraged the resident to frequently use the call light for assistance. The care plan indicated on 1/26/17 the resident fell from the bed and on 3/2617 the resident fell which resulted in a skin tear. Resident #13 Resident #13 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 03/12/18 at 08:08 AM, during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cord to make the light reachable for the resident. The call system control on the wall had a button to call and was not easily reachable for the resident. Resident #131 Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/12/18 at 08:20 AM, during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cord to make the light reachable for the resident. The call system control on the wall had a button to call and was not easily reachable for the resident. Resident #23 Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #23's care plan for fall risk, updated 11/23/17, documented interventions to encourage the resident to use call light for assistance and the call light should be placed in reach for assistance. On 03/12/18 at 08:31 AM, during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cord to make the light reachable for the resident. The call system control on the wall had a button to call and was not easy reachable for the resident. Resident #106 Resident #106 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #106's care plan, updated 11/20/17, documented interventions to include encouraging the resident to use the call light for assistance. Resident #106's nurse's notes, dated 01/22/18, indicated the resident had a fall on 01/22/18 and tripped near the foot of bed with no way to get help except to yell out. Resident #106's Morse Fall Scale assessment, dated 01/23/18, documented a score of 40. The document indicated score 25- 45 was a moderate risk for fall. On 03/12/18 at 08:32 AM, during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cord to make the light reachable for the resident. The call system control on the wall had a button to call and was not easily reachable for the resident. Resident #21 Resident #21 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #21's Morse Fall Scale assessment, dated 11/21/17, documented a score of 40. The document indicated score 25- 45 was a moderate risk for fall. Resident #21's care plan for fall risk, updated 11/21/17, documented interventions to include encouraging the resident to use the call light for assistance. On 03/12/18 at 08:35 AM, during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cord to make the light reachable for the resident. The call system control on the wall had a button to call and was not easily reachable for the resident. The resident verbalized she had to scream for the nurses when she needed to use the restroom. The resident could not find the call light and did not know how to activate the call light system, Resident #4 Resident #4 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #4's Morse Fall Scale assessment, dated 03/11/18, documented a score of 30. The document indicated score 25- 45 represented a medium risk for fall. Resident #4's care plan, updated 11/07/17, revealed the interventions included the resident was to use the call light and assure assistance devices are within reach of the resident. On 03/12/18 at 09:01 AM during the initial screen of the residents, it was noted the call system in bathroom and room did not have call cord to make the light reachable for the resident. The call system control on the wall had a button to call and was not easily reachable for the resident. The resident indicated there were no call light reachable to call the nurses for assistance. Resident #34 Resident #34 was admitted on [DATE], with diagnose (TRUNCATED)

Based on observation, interview, record review and document review, the facility failed to ensure a resident admitted with an indwelling catheter was assessed for removal of the catheter prior to two urinary tract infections for 1 of 25 sampled residents (Resident #112). Findings include: Resident #112 Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/12/18 at 2:16 PM, Resident #112 was in bed with an uncovered urinary catheter bag lying on the floor by the bedside. The Foley catheter tubing was kinked, and the bag contained approximately 50 milliliters of dark yellow urine. Resident #112 verbalized she felt leakage coming from the catheter and it made her wet. On 03/12/18 at 2:20 PM, a Certified Nursing Assistant (CNA) acknowledged the tubing had been twisted and the urinary bag should have been off the floor and covered. Resident #112's Nursing Admission Evaluation, dated 01/21/18, documented the resident was incontinent for bowel and bladder and with a Foley catheter. Resident #112's Bladder Evaluation, dated 01/21/18, documented incontinence as functional due to physical or cognitive limitation and may impair toileting. The resident status had been indicated as able and willing to follow instructions and treatment options and was to manage with adult incontinence products and pain management. Resident #112's Admission Physician Orders, dated 01/24/18, signed by an Advanced Practice Registered Nurse (APRN), documented under the catheter section the [DIAGNOSES REDACTED]. The order indicated to have the catheter changed as needed (PRN) for leakage/lockage/dislodgement and change the catheter bag every month and PRN. The catheter site needed care every shift and PRN. The indwelling urinary catheter box was left unchecked to include the French size and amount held in the balloon. Resident #112's clinical record lacked a physician's orders [REDACTED]. Resident #112's Physician Visit Note, dated 01/24/18, electronically signed by the APRN, documented under the chief complaint to see the attached note. The Medical Records Director was unable to provide the attached note during the length of the survey. Resident #112's Treatment Administration Record (TAR), dated (MONTH) (YEAR), had a circle around F/C to indicate the resident had a Foley catheter for your information (FYI). The TAR lacked size of the catheter, catheter and bag change, and monitoring for leakage or dislodgement. The TAR lacked documented evidence of catheter site care as indicated in the Admission Physician Orders. Resident #112's Nursing Documentation Flowsheets, dated 01/25/18, 01/27/18 and 01/31/18, documented the same note regarding the Foley catheter draining with concentrated urine. Resident #112's Physician Visit Note, dated 01/26/18, documented the resident had a chief complaint of nausea and diarrhea and indicated as a plan to have labs and urine culture. The physician visit lacked an assessment for removal of the catheter or a medical justification for the catheterization. The note was electronically signed by the APRN. Resident #112's Physician Telephone Order, dated 01/26/18, documented [MEDICATION NAME] 500 milligrams (mg), by mouth, two times a day, for five days for UTI. Resident #112's Care Plan for Urinary Tract Infection [MEDICAL CONDITION], dated 01/26/18, documented a goal of signs and symptoms decreased or minimized in 14 days. Resident #112's Medication Administration Record [REDACTED]. Resident #112's Care Conference Summary, dated 01/31/18, and signed by a Licensed Practical Nurse (LPN), Resident #112 and the Activity Director, documented the resident had been admitted from the hospital for the management of acute rhabdomyolysis (resolved), was receiving treatment for [REDACTED]. Resident #112's Care Plan for potential alteration in elimination due to Foley catheter and incontinence of bladder and bowel, dated 02/20/18, documented approaches and interventions were for the resident to be checked and changed every two hours, to use adult incontinent product to maintain dignity, catheter care per protocol, catheter and drainage system to be changed per MD order, to be evaluated for appropriateness of Foley catheter and discontinue within 72 hours if indicated. The TAR for (MONTH) (YEAR) and (MONTH) (YEAR) lacked documentation of the Foley catheter site care, changing catheter PRN for dislodgement or leakage, and catheter bag change monthly and PRN as indicated in the Admission Physician Orders. Resident #112's Physician Visit Note, dated 02/28/18, indicated a medication review was completed and documented the patient was without complaint. The physician visit lacked an assessment for removal of the catheter or a medical justification for the catheterization. The note was electronically signed by the APRN. Resident #112's Physician Visit Note, dated 03/02/18, documented the resident was evaluated for pain in her back where the pressure ulcer was located and prescribed pain medication. The plan revealed the resident was stable with no changes. The physician visit lacked an assessment for removal of the catheter or a medical justification for the catheterization. The note was electronically signed by the APRN. Resident #112's clinical record revealed acute hospital emergency room notes. The notes documented the resident had an appointment at the Wound Clinic on 03/08/18. The resident had complaints of irregular heartbeat during the appointment. Resident #112 was transported to the emergency room . Resident #112's physical evaluation, diagnostic studies and labs demonstrated the resident had normal sinus rhythm, no ongoing ischemia or infarct at the acute hospital emergency room . The resident's urinalysis showed dark cloudy urine, was positive for blood, protein, and moderate bacteria. Resident #112 was discharged with a final [DIAGNOSES REDACTED]. The recommendations documented from the acute hospital emergency room physician were to start treatment with an antibiotic and to have the Foley catheter changed after a few days of antibiotic. Resident #112's Physician Telephone Order, dated 03/08/18, documented Bactrim DS 800 mg-160 mg, one tablet by mouth two times a day for 10 days related to UTI. On 03/14/18 at 10:40 AM, the DON explained residents admitted with a Foley catheter need to have an order for [REDACTED]. The DON verbalized the monitoring for a Foley catheter site care was required to prevent complications and infections. The DON confirmed Resident #112's clinical record lacked documentation of Foley catheter monitoring by the facility since the resident's admission. On 03/15/18 at 11:00 AM, the APRN explained she [MEDICATION NAME] all the residents in the facility and knows them all. The APRN explained she had not been aware of Resident #112's Foley catheter from 01/22/18 to today's date. The APRN admitted she had found out Resident #112 had a Foley catheter three hours ago. The APRN confirmed she did not do an assessment for the Foley catheter or for the removal of the Foley catheter. The APRN explained on the initial visit, when the resident had been admitted , she looked only at the pictures on the Nursing Admission Evaluation and did not read anything else from Resident #112's admission evaluation. The pictures documented notes of redness and skin peeled on the genital area. The APRN admitted she did not take into consideration the redness if it was not a pressure ulcer. The documentation of the pressure ulcer stage 2 was indicated under the integumentary evaluation and the Foley catheter was indicated under the gastro-intestinal and genito-urinary evaluation, The APRN reviewed the Nursing Admission Evaluation and reiterated she only looks at the pictures and does not read the notes. The APRN verbalized she did not review the resident's five pages of the Admission Physician order [REDACTED].#112 had a catheter because she only reviewed the medications listed. The APRN confirmed it was her signature on Resident #112's Admission physician's orders [REDACTED]. Facility policy titled, Evaluation for indwelling catheters, updated 02/18, documented residents admitted with indwelling catheters were to have them removed when there was no valid medical justification. Each resident was to be evaluated at the admission for indwelling catheter usage and when possible, the indwelling catheter usage discontinued, and toileting/retraining initiated. Residents admitted with indwelling catheter and did not meet the clinical conditions should have catheter usage discontinued within 3 to 5 days as appropriate per physician order.

Based on record review, interview and document review, the facility failed to ensure alternate meals were offered to a resident with a meal intake less than 50 % for 1 of 25 sampled residents (Resident #283). Findings include: Resident #283 Resident #283 was admitted on [DATE], with [DIAGNOSES REDACTED]. Medical record revealed the resident was admitted with a weight of 104 pounds (Lbs). The record documented the resident's weight was 103 Lbs on 07/17/17 and 92 Lbs on 10/15/17. The resident experienced a severe weight loss of 10.6% in 90 days. Nutrition evaluation dated 06/28/17, documented the resident had poor intake and experienced a weight loss of three pounds since admission. The evaluation indicated 120 milliliters (ml) of an oral supplement was recommended to be administered three times daily as a nutritional intervention and 1500 ml of fluids as the estimated daily fluids needed. Meal monitor flowsheet for (MONTH) (YEAR), indicated alternate food had to be offered to residents with meal intake of 50% or less. The flowsheet documented the resident ate 50% or less or refused meals as follow: - Breakfast on (MONTH) 1, 3, 5, 8, 10, 12, 13,15, 18, 22, 23, 25, 26, 27, 29 and 30. - Lunch on (MONTH) 2 to 11, 15, 16, 19, 20, 22, 23, 25, 27, 29,29,30 and 31. - Dinner on (MONTH) 1, 2, 3, 4, 5, 7, 12, 13, 14, 15 and from 18 to 31. Meal monitor flowsheet for (MONTH) (YEAR), indicated alternate food had to be offered to residents with meal intake of 50% or less. The flowsheet documented the resident ate 50% or less or refused meals as follow: - Breakfast on (MONTH) 8, 9, 10, 13, 20, 23 and 25. - Lunch on (MONTH) 1, 2, 5, 6, 7, 8, 13, 14, 16, 17, 18, 19, 25, 27 and 30 - Dinner on (MONTH) 1, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 17, 19, 20, 21, 22, 23, 24, 25, 26, 27, 29 and 30. Meal monitor flowsheet for (MONTH) (YEAR), that indicated alternate food had to be offered to residents with meal intake of 50% or less. The flowsheet documented the resident ate 50% or less or refused meals as follow: - Breakfast on (MONTH) 1, 2, 3, 4, 5, 6, 7, 9, 10, 12, 13 and 14. - Lunch on (MONTH) 1, 3, 4, 5, 7, 10 and 14. The meal monitor flowsheets lacked documented evidence alternate meals were offered when the resident meal intake was 50% or less. There was no evidence the supplement and the required amount of fluids were administered as per Registered Dietitian recommendations and physician orders. The medical record lacked documented evidence an Interdisciplinary assessment was performed. Nutrition and hydration care plan, dated 10/12/17, revealed interventions included encourage the resident to eat more than 50% of the meals, monitoring meal intake and offer alternate or supplement if the intake was less than 50%, observe for signs of symptoms of dehydration and refer to a Registered Dietitian as appropriate were not check marked. Care plan for self-care deficit, dated 6/21/17, documented goals included staff to assist the resident performing activities of daily living if they could not be met by the resident. The approach plan included the assistance with meals. Nurse's note, dated 10/15/17 at 09:15 AM, indicated the resident was found unresponsive in the dining room. The note documented the resident was transferred to an acute care facility. Medical record from the acute care facility revealed the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. On 03/15/18 at 4:00 PM, The Director of Nursing (DON) confirmed the finding and indicated alternated meals should have been offered to the resident. On 03/15/18 at 4:20 PM, a Registered Dietitian (RD) explained Resident #283 was refusing meals with poor meal intake. The RD explained the resident experienced weight loss and interventions were implemented to prevent a worsened condition, the interventions included supplements three times daily, monitoring weight and medication regimen review. On 03/15/18 at 4:35 PM, a Certified Nursing Assistance (CNA) explained if a resident's meal intake was 50% or less, an alternate food should be offered and documented if the resident ate or refused the alternate. Facility policy titled, Meal Supervision Guidelines, updated (MONTH) 2012, documented dining room staff should encourage residents to eat, offer alternate food when meals were refused and communicate any concern to the Dietary Manager.

Based on observation, interview, record review and policy review, the facility failed to protect a resident from harm for 1 of 6 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. In an interview at 10:15 AM on 9/14/15, Resident #1 recounted the events of 1/29/15, while being transported to an appointment in the facility van. According to the resident the straps holding the wheelchair were not properly secured in place, resulting in loosening and causing the resident to fall forward while seated in the wheelchair. The resident indicated he landed on the floor of the van on the right side. The resident indicated his right clavicle was fractured. The resident stated before the incident the driver pulled out fast then the van came to an abrupt stop causing the resident's wheelchair to fall forward. The resident insisted he and the wheelchair fell forward when the straps loosened and or gave way. The resident confirmed this information in a second interview at 9:00 AM on 9/15/15. Resident #1 revealed that after the 1/29/15, incident he reminds the van driver to tighten the straps especially involving heavy traffic situations. The resident expressed concern about the van driver's experience transporting residents. Following the 1/29/15, incident, the resident complained of pain in the right shoulder/clavicle area and was sent to the hospital emergency department for treatment. The resident was sent back to the facility with instructions for a Clavicle Fracture. Resident #1 also indicated he was sent back to the facility with an arm sling for immobilization. During the interview, the resident was observed rubbing the right shoulder/clavicle area and verbalized continuing pain in the area. A review of the clinical record noted an X-ray taken on 2/25/15, revealed, .a healing right distal clavicle fracture showing near anatomical alignment. The document signed by the radiologist concluded, a healing fracture. Further review of the clinical record revealed a physician progress notes [REDACTED]. -Seen for: Clavicle Fx. (Fracture) -S (symptoms): Pt. (patient) fell yesterday and fractured his R (right) clavicle, having more pain now. -A/P (assessment/plan): Clavicle Fx-pt has a fractured clavicle and increased pain due to this. Pt had been well controlled with his pain since starting methadone. Pt has 20 mg (milligrams) Oxycodone available every 4 hours as needed, don't want to increase that therefore will increase methadone for now to help control pain from the fracture. Review of the physician's orders [REDACTED]. Methadone 10 mg, 2 PO TID pain. Another physician order [REDACTED]. Review of the Medication Administration Record (MAR) following the above order indicated the resident received increased medication three times a day beginning on 1/30/15 at 2:00 PM through 7/27/15. The MAR indicated in addition to the increased Methadone the resident continued to request additional medication for pain. As such, in the days following the injury the resident requested Oxycodone 10 mg, available as needed (PRN) 1 every four hours for increased pain related to the clavicle fracture. Review of the Interdisciplinary Progress Note dated 1/29/15, indicated Resident #1 was sent to the hospital emergency department and returned with a right clavicle fx . Moreover, the note indicated the staff involved was re-educated .to ensure belts are always double checked and secured properly. The note further indicated the resident thought the bus had flipped over. In an interview at 8:30 AM on 9/14/15, the Maintenance Director identified the measures taken after the 1/29/15, incident. The Maintenance Director checked the straps through inspection, applying force, and sitting in a wheelchair with the straps set in place moving around forcefully in an attempt to dislodge the straps. The Maintenance Director indicated there was nothing wrong with the straps or the floor attachments. Additionally, the Maintenance Director said he thought it was operator error that caused the resident to tip over meaning the straps were not secured either because the driver lacked knowledge or simply did not secure the straps tight enough. Also, the Maintenance Director mentioned it was essential the straps be placed at a 45 degree angle to secure the wheelchair and keep it from moving at all. And although the Maintenance Director denied knowledge of proper strap placement/angle used in the 1/29/15, incident he provided instruction to the current van driver on proper strap placement/angle after a second incident on 4/27/15. During the above interview, the Maintenance Director revealed his only involvement in maintaining the van was if or when something needed repairing or replacing. The Maintenance Director indicated the van driver was responsible for performing daily inspections and completing the van log. The Maintenance Director was responsible for orienting new van drivers however did not orient the driver assigned to drive the van on 1/29/15, when the resident was injured. The Maintenance Director was also responsible for the preventative maintenance to the van, yet failed to produce a record of documented preventative maintenance before survey exit. An interview with the employee driving the van on 1/29/15, the day of the incident, was not possible as the driver had been terminated for a different incident. However, review of the personnel file established the employee as the driver on 1/29/15. The file indicated following the incident the driver had been given a Performance Coaching dated 1/29/15, identifying the concern as, failure to secure the resident/wheelchair appropriately in the transport van resulting in injury to the resident. The corrective interventions included, re-education on applying safety devices and re-checking those devices to ensure the resident and the wheelchair were secured in place. The form indicated any further incidents related to safety could result in termination. The personnel file indicated the employee was hired 2/11/09, was applying for a NAT/CNA (Nurse Assistant in Training/Certified Nurse Aide) position. A review of a form titled Nursing Assistant Orientation and Skills Checklist dated 10/12/10, and signed by a supervisor, lacked a reference to skills required to drive a van. The employee's job description signed 2/22/10, included transporting residents, using wheelchair or wheeled cart, or assisting residents to walk, however the job description lacks any reference to driving a van, safety or other responsibilities related to transporting residents in a vehicle of any kind. According to the form titled Disciplinary Action Form dated 4/2/15, the employee was terminated on 3/26/15 for a pattern of negligence, carelessness and substandard care to the residents. On 9/14/15, review of three additional personnel records of employees identified by the Administrator as qualified to drive the transport van revealed conflicting information. Three of the four employee files lacked a job description that included driving a transport van as one of the responsibilities. The fourth, job description was titled, Driver and included under Essential Functions #4, Secure residents in the van with wheelchair wheel locks, seatbelts, and other safety straps or tie downs prior to movement of the vehicle and #8, conduct routine vehicle inspections to maintain safe operation of the vehicle. Only one of the four included a form titled Healthcare Personnel Action Form (PAF) signifying the employee moved from CNA to Transportation/CNA. The employee was not driving the transport van on 1/19/15. On 9/14/15, the Administrator provided forms titled Transport Training-Competency for each employee (4) currently authorized to drive the van. The form included a checklist of tasks the driver should be able to perform when qualified to drive the transport van. The Administrator explained this form was in place before the 1/29/15, incident involving Resident #1, however an evaluation of competency was not completed on the driver in the 1/29/15, incident because the employee was terminated on 3/26/15. In an interview at 8:30 AM on 9/15/15, with the former van driver (prior to 1/29/15) who drove the transport van since 2010, indicated she reviewed the associated tasks included on the above mentioned form, yet was unable to produce written verification of the review. The employee further indicated the 1/29/15, van driver had only been driving the van for one week prior to the incident with Resident #1. On the afternoon of 9/15/15, an interview with the current van driver revealed another similar incident on 4/27/15, where Resident #2 was thought to be strapped in fell backward while the van was pulling out of the parking lot and sustained a bump to the back of the head. In that case, as in the first, the resident and the wheelchair fell backward all at once. In an interview in the morning of 9/15/15, Resident #2 described the events of 4/27/15, indicating both the wheelchair and the resident fell backward resulting in a head injury. The resident further explained the paramedics came to the facility parking lot to check out the injury. The resident indicated the injury resulted in a headache for a few days. Since the 4/27/15, incident the resident has, on at least one other occasion, had to remind the van driver to tighten the supporting straps that hold the wheelchair in place. Review of facility policy titled, Transportation dated 5/2002, and followed prior to the 1/29/15, incident merely outlined the procedure for coordinating appointments absent information pertaining to actual transport activity including any measures in place to ensure the safety of the residents. Additionally, the policy designated the Activities Maintenance Director as responsible for transport activity. The Administrator confirmed that was the policy prior to 1/29/15. A review of the form titled, Preventative Maintenance Task Sheet from 2/2/15 to 9/14/15, listed the daily tasks such as proper operation and condition of seatbelts/straps, inspection performed before taking the transport van from the facility. Both the current and past transport driver were unable to locate the daily checklist before 2/2/15. Despite repeated requests on 9/14/15 and 9/15/15, for the Owner's Operating Manual for the van, none was produced. Thus the facility lacked any formal instruction pertaining to the maintenance of the equipment inside the van or identified safety precautions. Complaint #NV 153

Based on observation, clinical record review, interview and policy review, the facility failed to ensure residents were provided care that was appropriate, timely and with respect to the individual resident for 7 of 40 residents (Resident #7, #26, #11, #31, #21, #9 and #10) and that residents could express concerns without fear of neglect for 3 of 3 random/unsampled residents. Findings include: Resident #7 Resident #7 had been a resident for two years, with primary [DIAGNOSES REDACTED]. Resident #7's responsible party was a state appointed guardian. Review of the resident's condition indicated she required maximum assistance for all activities of daily living. The risk assessments for pressure ulcers performed throughout 2012 and 2013 did not identify Resident #7 as to high risk for pressure ulcers. Clinical documentation revealed Resident #7 developed what appeared to be a sudden onset, stage four pressure ulcer of the left antecubital (inner elbow) area, with a tendon exposed in October 2013. Clinical record review revealed the stage four pressure ulcer was identified on 10/12/13. The following events were transcribed. 1) According to documentation, Resident #7 had a weekly skin assessment performed on 9/28/13, and did not have another skin assessment performed until 10/26/13. 2) There was no weekly skin assessments performed on 10/5/13 and 10/12/13. Documentation indicated the resident refused these assessments. There was no evidence that either the physician or the guardian were informed Resident #7 was refusing skin assessments. 3) There was no skin assessment documented on 10/19/13 or any indication why it had not been performed. Review of the clinical nursing notes for Resident #7 revealed although wound/skin assessment forms as well as adjusting of the plan of care and interventions were instituted for identified bruises of the arms and legs, there was no in depth wound/skin assessments, interventions, and timely physician follow-up documented for the stage four pressure ulcer of the antecubital. Documentation revealed: 10/12/13: "Resident has an open sore at left antecubital." This entry was signed by Employee #12, who was a registered nurse. There was no evidence of any detailed assessment or measurement of the wound, or a wound care sheet initiated. An order was received for wound care, but there was no documentation that this wound care was provided. 10/15/13: The resident was taken to a wound clinic for evaluation and treatment, and new orders were received. It was determined the wound was a stage four pressure ulcer, and the tendon was exposed. 10/16/13: An interdisciplinary note indicated the wound on Resident #7's antecubital area was 4.5 centimeters (cm) long by 3 cm wide and 0.2 cm deep (1.75 inches long, 1.25 inches wide and one quarter inch deep). This was the first documentation of the size of the wound. There was no documented measurements of the wound for the four days after the first indication that it was present. 10/24/13: Approximately 16 days after the initial event, a late entry was written on this date to indicate that on 10/8/13, the physician was informed "necessity for resident's left elbow, lateral redness and open area to be assessed," written by a licensed practical nurse (LPN). The nursing staff indicated this was entered into the communication book for the physician, however the nursing staff also confirmed the communication record entries were discarded, and the facility could not provide any evidence the physician was informed on 10/8/13. There was no indication the physician or designee assessed this wound until 10/12/13, four days later. There was no evidence the professional nurses reported the lack of physician response to either the facility or the medical director. There was no evidence the LPN reported this wound to the Director of Nursing or the wound care nurse for more in-depth assessment. The facility could not provide any evidence of any thorough assessment of the left elbow wound, no wound assessment or skin assessment sheets for October. A wound/skin evaluation form was initiated on 11/12/13 to describe the condition of the stage four antecubital wound, approximately 34 days after it was first identified. This sheet only included two wound assessments: 11/12/13 and 11/18/13. Review of all the data provided resulted in the concern that Resident #7 did not receive appropriate care or interventions even though nursing identified problems. Cross Refer F 314 Resident #26 Resident #26 has resided in the facility since 2008, with [DIAGNOSES REDACTED]. Review of the doctor progress notes revealed an entry on 1/2/13, that a "...horny lesion was present over the resident's left eyebrow." On 2/2/13, the progress notes indicated the resident was refusing showers, and staff were to try bed baths. An entry on 8/27/13, revealed the area over the left eyebrow had deteriorated, "...very large [MEDICAL CONDITION] above left eye that involves area size of tennis ball and began to occlude vision, raw and erosive." A report on 10/25/13, revealed Resident #26's wound over the left eye became visible and was infected with maggots. A description in the facility report was this lesion extended from the left eye, side of face and back of head. The resident was sent to the emergency room for further evaluation and treatment. Wound evaluation sheets revealed there was no further description of this wound as far as size except that the resident refused the wound to be measured. Wound care forms revealed Resident #26 consistently refused wound care to the area, but there was no evidence that any visual observations of the wound dressing were performed, attempts to ensure no further maggot infestation or descriptions of any drainage, odor, swelling or pain were performed. There was no further description of a visual observation of the size of the wound. Review of Resident #26's care plans revealed although the refusal of bathing, wound care or personal hygiene was identified including Resident #26's fear of falling if moved, there were no specific interventions as what approaches were effective to provide care. There was no entry regarding the physician recommendation that 'bed baths" were to be performed, There was no care plan regarding the occurrence of maggots in the wound. An interview with the current Director of Nursing and the current wound care nurse acknowledged that Resident #26 did refuse wound care, but could be encouraged to allow staff to perform it if staff cajoled the resident into allowing the care. Cross Refer F 309 Random Resident Interviews: Random spontaneous interviews were attempted with three cognitive residents as part of the survey process. These interviews were conducted individually throughout the course of the survey. All three residents voiced concerns that they did not want to be seen speaking to the surveyors in the presence of staff. All three voiced a desire to remain anonymous. These residents expressed concerns that if they were seen speaking to the surveyors there would be repercussions from staff; such as not answering call lights or not following up on requests. Two residents expressed a fear that if they were seen talking to surveyors they would be "kicked out of the facility," and the third expressed staff retaliated by poor care. These residents voiced concerns that the certified nursing assistants would not provide assistance saying "...that resident wasn't assigned to" that aide, and that residents would be left on bedside commodes or toilet for long periods of time, calling for help. Resident # 11 Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Prior to the survey, the facility's self report dated 9/11/13, for Resident #11 was reviewed. The report indicated the resident had reported, between the dates of 8/28/13 and 9/11/13 involving the hours between 6:00 AM and 7:00 PM, three certified nursing assistants (CNAs) failed to provide the resident with adequate or proper peri care on a consistent basis. The report indicated an interview was conducted with all three of the CNAs, the CNAs indicated "they could/should be more thoroughly cleanses resident and applying creams." The report indicated the following actions were taken: "All 3 CNAs received counseling and reminded of importance of quality resident care." There was no evidence in the report to indicate that the CNAs had been retrained on the facility's policy and procedure on peri care, or that the CNAs technique and/or skills in delivering peri care were observed or monitored. On 1/30/14 at 7:40 AM, an interview was conducted with Resident #11. The resident indicated he recalled the 9/11/13 incident when he had reported the aides were not cleaning and/or giving him adequate peri care. The resident indicated one aide was not washing him off between changing his soiled brief, while other aides were not cleaning off the old peri cream, but were just applying more cream on top of the existing cream when they changed him. The resident also recalled going to the emergency roiagnom on [DATE], and indicated when the doctor examined him, the doctor indicated he was going to report the situation as he (doctor) thought the resident's condition was a result of neglect. On 2/3/14, Resident #11's medical records were reviewed. - Progress Notes dated 8/31/13, by the physician's assistant indicated the following: 1) resident was complaining of pain at the scrotum with a pain level of six to ten, 2) severe [DIAGNOSES REDACTED] (redness) with skin breakdown at the scrotum, 3) scrotal rash, [MEDICATION NAME] not effective start [MEDICATION NAME] cream twice a day for ten days, change diaper frequently. - A Progress Note dated 9/6/13, by the physician, indicated the following: 1) scrotal [DIAGNOSES REDACTED], skin tenderness, skin impairment, 2) scrotal [MEDICAL CONDITION], and 3) scrotal [MEDICAL CONDITION] continue with topical treatment avoid scrubbing skin. - Another Progress Note dated 9/25/13, by the practitioner indicated the following: 1) increase [DIAGNOSES REDACTED] and tenderness to scrotum, 2) concerned about [MEDICAL CONDITION] 3) sending to ER for evaluation, 4) needs urinalysis and lab work? start antibiotic. Resident #11's care plans failed to provide evidence that a care plan had been developed to address the scrotal irritation and skin breakdown. Review of Resident #11's Nurse's Notes indicated the resident was sent to the emergency room (ER) on 9/20/13, to be evaluated and for the treatment of [REDACTED]. The emergency room discharge instructions, dated 9/20/13 at 1:20 PM indicated the following: 1) scrotum inflammation, 2) clean scrotum with [MEDICATION NAME] soap and water twice daily, dry thoroughly and apply Gold Bond Powder to the scrotum to keep area completely dry, 3) change wet or soiled diapers immediately, 4) follow up with Dr. (urologist) in 5 to 7 days for a recheck, 5) return to ER sooner if any new problems develop before you see urologist. On the copy of the discharge instructions, there was an added hand written note by the facility staff dated 9/21/13, which indicated: 1) per (practitioner) change gold bond powder to peri guard (cream), and the words Gold Bond Powder were crossed through with a single line. There was no evidence in the resident's record that the complete documentation of the ER visit had been obtained by the facility. There was also no evidence that the follow-up appointment with the urologist, had been made. Additional Nurse's Notes indicated the following: - 9/21/13 2:00 PM, Practitioner made aware resident came back from the ER yesterday with order to clean scrotum with soap and water, pat dry, apply peri guard twice a day, mild redness noted in scrotum area ... - 9/22/13 1:00 PM, peri care given, cleaned with soap and water pat dried and applied peri guard as ordered. Scrotum and peri are still red, complains of discomfort to scrotum upon palpation/touch.... - 9/23/13 1:15 PM, cleaned peri area and scrotum with soap and water, pat dried and applied peri guard as ordered, peri area less redness noticed today. Scrotum remains enlarged. Review of Resident #11's weekly skin assessments for the period of July 2013 through December 2013, failed to identify concerns related to the condition of the scrotum. Although, the review of Resident #11's ADL Flowsheets for the period of September 2013 to January 2014, indicated the resident was incontinent of bowel and bladder. On 2/5/14, in a random interview with one unidentified nursing assistant, the assistant indicated the resident was continent and could let you know when he needed to go to the bathroom. On 2/5/14 at 8:15 AM, the self report and record review findings were discussed with the Director of Nursing (DON - Employee #2). The DON confirmed the facility had not obtained the complete documentation of Resident #11's 9/20/13 ER visit, and a follow up visit with the urologist had not been made. The DON confirmed a care plan had not been developed and agreed the weekly skin checks were either not completed or were inadequate in the documentation of the Resident #11's situation. On 2/5/14 at 9:00 AM, the complete documentation of Resident #11's ER visit was obtained and reviewed. The documentation revealed the following: - History of Present Illness: ... presents with complaints of persistent [DIAGNOSES REDACTED] and tenderness to the scrotum over the past 4-5 weeks... has been seen by several practitioners in the nursing home ... and has been treated with various ointments... not getting any better... currently having barrier cream applied to the area... denies any other medical complaint other than the persistent scrotal inflammation... states at the nursing home where he resides, often times he has great difficulty in getting his diaper changed due to the workload of the nursing staff... states at times he was forced to urinate in his diaper due to their inability to assist him to the commode... - Physical Examination: ... Scrotum is [DIAGNOSES REDACTED]tous and tender to palpation... no evidence of [MEDICAL CONDITION] to this area... - Hospital Course: I (doctor) did discuss the case with (name), on call urology. He suggested a course of daily soap and water, cleaning of the scrotum followed by application of Gold Bond powder to keep the area completely dry. Discontinue all ointments or creams. This care was given to the patient in the Emergency Department... -Final Diagnosis: [REDACTED]. Other Interviews, Resident/Group Counsel Interviews and Minute Notes, and Record Review: On the afternoon of 2/1/14, in an interview with a group of residents, one resident indicated it was sometimes difficult to get assistance after staff had assisted them into the bathroom. This resident indicated they recalled waiting as long as 30 minutes to get assistance after using the bathroom. On 2/3/14, a family member was interviewed. The family member reported she was going to call the number on the survey in process sign after the survey exit, as she did not want to be seen talking to the survey team for fear of retaliation to her husband. On 2/3/14 at 2:30 PM, a group interview was conducted. The residents reported the CNAs were overheard talking, laughing, and making fun of residents' bowel movements. The residents reported they felt they were being made fun of and humiliated. Review of resident council meeting minutes from 1/14/14, revealed the following concerns: 1. Medications not getting to residents within the scheduled time. Residents are in pain, and waiting for their medications. 2. Resident #30 had been left in a soiled brief for two hours. 3. Certified nursing assistants (CNAs) hide in the break room. 4. CNAs turn off call lights and tell the resident they will be "right back" and do not come back. 5. Alert and oriented resident reports he has waited three hours for response to his call light. 6. Residents report shower schedule needs to be looked at: A. Resident #36 reported he had been 12 days without a shower. B. Resident #35 reported it had been five days without a shower. Resident reports CNAs tell her "tomorrow is shower day for you". Resident reports the next day she is not showered. Review of the facility self-reports prior to the survey revealed 67 resident to resident altercations had occurred in the facility since January 2013. The majority of the resident-to-resident altercations occurred on Station II or Station III. Resident #31 Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility's self-reported incidents revealed on 1/3/14 at 10:20 AM, Resident #31 had his call light on for assistance to the bathroom. Per the report, a social worker answered the call light, then left to find someone to assist the resident. Per the report, the social worker returned to the room to see if the resident's needs were met, and at that time, the resident informed the social worker a certified nursing assistant (CNA, Employee #5) had told him to "go in his brief." Per the report, the CNA was suspended pending investigation, then terminated when the allegation was substantiated after investigation. Review of the facility's schedules revealed CNA-Employee #5 was working in the facility during the survey 1/30/14 -2/10/14. On 1/30/14, the Director of Nurses was interviewed and confirmed CNA-Employee #5 had been re-hired by the new Administrator. (See Tag F-226). Resident # 21 Resident #21 was admitted to the facility on [DATE], with a re-admitted s of 7/29/13 and 12/12/13, with [DIAGNOSES REDACTED]. Review of Resident #21's admission orders [REDACTED]. The resident was on [MEDICATION NAME] 500 milligrams (mg) twice a day for a [DIAGNOSES REDACTED]. Review of the MARs for May 2013, June 2013, and July 2013, revealed a FSBS was conducted daily at 8:00 AM through 7/24/13, when the resident was transferred to an acute care hospital. Review of the residents' physician orders [REDACTED]. Resident #21 was re-admitted on [DATE]. Review of the resident's admission orders [REDACTED]. The resident continued on [MEDICATION NAME] 500 mg twice a day for diabetes mellitus. Review of the MARs revealed the finger sticks were done for seven days. Review of the October 2013 and November 2013 physician order [REDACTED]. Review of the physician progress notes [REDACTED]. The APN documented "DM-stable" on 9/12/13, 9/19/13, 9/28/13, 10/16/13, and 10/26/13. On 9/12/13, a physician documented the chart was reviewed and "agree with plan." On 11/13/13, the resident was seen by a physician, the physician documented medically stable. On 11/14/13, the resident was seen by a physician assistant (PA) and the documentation was "no change in patient status, continue medications." On 12/8/13, the PA saw the resident, and documented, "no complaints and no s/s (signs/symptoms) of distress." Sometime that same day, the APN saw Resident #21 for altered mental status and lethargy. On 12/9/13 at 12:39 PM, the APN documented the resident had increased respirations of 32 (normal adult rate is 12-20), "very dry oral mucosa", "dry gangrene right second toe" and a blood sugar of 692. The APN wrote "severe dehydration, acidosis, uncontrolled DM, and leukocytosis. The resident was transferred to an acute care hospital. Review of Resident #21's record revealed no vital signs were documented since 11/17/13. There was no documentation of FSBS. No labs had been drawn on the resident since his July 2013 hospitalization . On 2/4/14, the Director of Nurses (DON) reviewed Resident #21's record and confirmed there should have been vital signs recorded at least weekly. The DON confirmed the FSBS order should have been clarified. Review of Resident #21's discharge summary from the acute care hospital revealed the resident was admitted for "hyperosmolar nonketotic state, there may be a component of diabetic ketoacidosis." The resident was aggressively rehydrated with intravenous fluids, treated with sliding scale insulin coverage. The resident was admitted to the hospital for four days, transferred back to the facility on [DATE]. The following day, 12/13/14, the resident was transferred back to an acute care facility, for "right lower extremity limb threat." The resident required an above the knee amputation of the right leg. On 2/11/14, Resident #21's wife was interviewed and reported she did not know the facility had not been doing finger stick blood sugars, as no one had advised her of the change in treatment plan. Resident #21's wife reported she came to the facility daily to see her husband and attended all the care plan meetings. Resident #21's wife reported she had performed the finger sticks for her husband for years. Resident #21's wife reported the surgeon advised her if the limb threat had been identified earlier, most of the leg may have been able to be saved. Resident # 9 Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was Spanish speaking. On 2/6/14 at 1:00 PM, Resident #9 was interviewed with her daughter and an interpreter. Resident #9 reported she tries to do as much as she can for herself, but that sometimes she needs assistance and turns on her call light. Resident #9 reports the CNAs come into her room and turn off the call light without taking care of her need. Resident #9's daughter reports the resident is unable to express what she actually needs because she is Spanish speaking. At this time the resident began crying, expressing, "It's my fault. I should have learned English long ago." Resident #9's daughter reported her mother had lived and worked in Michigan for [AGE] years, but she had not learned to speak English. Resident #9's daughter reported there was a communication board in English and Spanish addressing basic needs, such as thirst, hunger, and need to go to the bathroom. Resident #9's daughter reported she had called the facility three times beginning in January 2014, requesting a dental appointment, as her mother continued to complain of dental pain. The dental appointment was made for 2/7/14 (after the state agency survey team brought the concern to the Director of Nurses). Review of Resident #9's record revealed the following entry on 6/5/13 at 1:45 PM, resident stated she "changed herself because she was waiting for CNA who was finishing up with another resident. Resident advised nurse she waited at least 30 minutes so "I changed myself." Resident #10 A resident reported a CNA left Resident #10 in his wheelchair facing the double doors for approximately 45 minutes. Resident #10 was totally dependent on staff for mobility and all activities of daily living. Resident #10 was unable to express his needs, and was observed responding to staff and other residents by turning his head and smiling. The reporting resident tried to assist Resident #10 to his room so Resident #10 could hear the television. Policy Review Review of the facility's policy, "1.01, Abuse Neglect and Misappropriation of Resident Property Prohibition," publish date of December 2003, update November 2013, revealed the definitions as: Abuse: "The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. 42 CFR 483.13(b) and (c) in the State Operations Manual also include the definition of abuse, the willful deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well being." Verbal Abuse: "The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability." Mental Abuse: "Includes but is not limited to coercion, harassment, inappropriately isolating a vulnerable adult from family, friends, or regular activity, and verbal assault that includes ridiculing, intimidating, yelling or swearing." Neglect: "Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness." Complaint #NV 048

Based on resident interview, record review, staff interview and policy review, the facility failed to ensure the residents' physician were notified of missed medication administration for 2 of 40 residents (Resident #15 and Resident #7) and refusal of treatments for 2 of 40 residents (Resident #7 and Resident #26). Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's medications included [MEDICATION NAME] 45 milliters to be administered by mouth every six hours (total of four doses per day), for the treatment of [REDACTED]. Note: Elevated ammonia levels, which are a result of hepatic [MEDICAL CONDITION], is commonly treated with the administration of [MEDICATION NAME]. [MEDICATION NAME] is used to both decrease elevated blood ammonia levels and to maintain ammonia levels within acceptable parameters on an ongoing basis. Early signs of an elevated ammonia level include slight personality changes (disorientation, forgetfulness, slurred speech) and a slight tremor. Symptoms can progress to a comatose state if left untreated. Review of Resident #15's medical records revealed the resident had a history of [REDACTED]. On the afternoon of 2/3/14, during a group meeting to discuss concerns, Resident #15 indicated she had not received her medication ([MEDICATION NAME]) in several days. The resident indicated she could tell her ammonia levels were starting to rise. After the resident left the meeting, two other residents, that had attended the meeting, indicated they could see a difference in Resident #15's behavior and thought it might be due to her not getting her medication. Following the meeting, Resident #15's medication administration records (MARs), for January 2014 and February 2014, were reviewed. Between Thursday January 30, 2014 and Monday February 3, 2014, there were a total 18 doses of [MEDICATION NAME] that were not administered to the resident. It was documented, the doses had not been given due to being out of the [MEDICATION NAME]. On Saturday 2/1/14 at 4:00 PM and 8:00 PM, it was documented: "[MEDICATION NAME] reordered at pharmacy via fax." On Sunday 2/2/14, it was documented for the 4:00 PM and 8:00 PM doses: "[MEDICATION NAME] out, pharm (pharmacy) will send on Monday." On Monday 2/3/14 at 8:50 AM, it was documented: "[MEDICATION NAME] not arrived from Rx (pharmacy) - to fax re-Fax x 2." On 2/4/14, review of Resident #15's medical record failed to provide evidence that the physician was notified of the missed doses of medications ([MEDICATION NAME]). On the afternoon of 2/4/14, the findings for Resident #15's medication and medication record were reviewed with the Director of Nursing (DON - Employee #2). The DON confirmed the physician had not been notified, and indicated the physician should have been notified right away of the missed doses. The DON indicated there were provisions in place for obtaining refills on the weekends. The DON indicated she was aware of the resident's history of developing increased ammonia levels and related falls. Review of the facility's policy titled, "1.0 Providing Pharmacy Products and Services," with the effective date of 12/1/07, indicated the following: - Procedure: 1. Pharmacy will provide the Facility with a facility-specific information sheet that details how the Facility staff can contact the Pharmacy twenty four (24) hours a day, seven (7) days a week. (See Appendix 1-Pharmacy Services Overview)., 4.1.1 If a drug cannot be substituted, Facility staff should ask the prescriber if the drug therapy can be initiated the next morning. If it is possible to initiate the drug therapy the next morning, Facility staff should document its conversation with the prescriber and include the start time in the order. 4.1.2 If a drug is considered essential and cannot be substituted or delay, Facility staff should contact the emergency number provided by the Pharmacy... Review of the facility's policy titled, "2.0 Resident Medication Rights," with the effective date of 12/1/07, indicated the following: - Procedure: 1. Facility should notify physician a resident's refusal of treatment... 2. Facility should notify Prescriber of a resident's refusal of medications/treatments for periods greater than twenty four (24) hours. Facility should notify Prescriber immediately if the refused drug could affect the health or safety of the resident. 3. Facility should document the effect of refused drugs, treatments or doses in the Resident's clinical record. Review of a staff training titled, "Medication Treatment Unavailable or Refusals," presented to staff on 1/13/14, outlined the following: - It is not acceptable to just not give a medication because your cannot find it or it is unavailable from the pharmacy. - 1. If a medication has not arrived from pharmacy in a timely manner and your are unable to administer the medication when it is ordered, you must notify pharmacy immediately to get that medication delivered and notify the medical provider for further instruction. This must be documented. Also please notify the DNS (Director of Nursing Services) or ED (Executive Director (Administrator)) if there is any further problems with this medication delivery. - 3. Refusals cannot just be circled. They also have to be charted on the back of the MAR (Medication Administration Record) of why they refused and what you did to educate or encourage them for compliance with the med/tx (treatment) plan. Resident #7 Resident #7 had been a resident for two years, with primary [DIAGNOSES REDACTED]. This resident had an appointed guardian. Clinical record revealed the following nursing note documentation: 10/12/13, an open sore on Resident #7's left antecubital (inner elbow) area. On 10/15/13, this wound was evaluated at a wound clinic, and determined to be a stage four pressure ulcer. Wound care was ordered to be performed daily. There was no documentation to indicate the responsible party was notified. A prescription for [MEDICATION NAME] ophthalmic ointment was also prescribed to treat [MEDICAL CONDITION] on 10/16/13, however documentation revealed that on 10/16/13, the responsible party was only informed that a prescription for Zinc mineral was ordered. Documentation revealed the guardian was not informed about Resident #7 having a wound and needing wound clinic treatments until a message was left on 10/21/14. The facility did not have any direct contact with the guardian until 11/20/14. Review of the wound care treatment sheets revealed that in the month of October 2013, Resident #7 refused wound care four of 11 days but there was no documentation this was relayed to the physician or the guardian. Documentation revealed: 10/12/13: "Resident has an open sore at left antecubital." This entry was signed by Employee #12, who was a registered nurse. There was no evidence of any detailed assessment or measurement of the wound, or a wound care sheet initiated. An order was received for wound care, but there was no documentation that this wound care was provided. 10/15/13: The resident was taken to a wound clinic for evaluation and treatment, and new orders were received. It was determined the wound was a stage four pressure ulcer, and the tendon was exposed. 10/16/13: An interdisciplinary note indicated the wound on Resident #7's antecubital area was 4.5 centimeters (cm) long by 3 cm wide and 0.2 cm deep (1.75 inches long, 1.25 inches wide and one quarter inch deep). This was the first documentation of the size of the wound. There was no documented measurements of the wound for the four days after the first indication that it was present. 10/24/13: Approximately 16 days after the initial event, a late entry was written on this date to indicate that on 10/8/13, the physician was informed "necessity for resident's left elbow, lateral redness and open area to be assessed," written by a licensed practical nurse (LPN). The nursing staff indicated this was entered into the communication book for the physician, however the nursing staff also confirmed the communication record entries were discarded, and the facility could not provide any evidence the physician was informed on 10/8/13. There was no indication the physician or designee assessed this wound until 10/12/13, four days later. There was no evidence the professional nurses reported the lack of physician response to either the facility or the medical director. There was no evidence the LPN reported this wound to the Director of Nursing or the wound care nurse for more in-depth assessment. The facility could not provide any evidence of any thorough assessment of the left elbow wound, no wound assessment or skin assessment sheets for October. A wound/skin evaluation form was initiated on 11/12/13 to describe the condition of the stage four antecubital wound, approximately 34 days after it was first identified. This sheet only included two wound assessments: 11/12/13 and 11/18/13. Review of the medication record revealed Resident # 7 was prescribed Keflex 250 mg (milligrams) every six hours for 10 days (2:00 AM, 8:00 AM, 2:00 PM and 8:00 PM). This order was obtained at 12:15 AM on 11/2/13. Documentation revealed on 11/2/13, three doses were not given. The first dose was administered at 8:00 PM on 11/2/13. On 11/9/13, 11/11/13 and 11/12/13, the 2:00 AM dose was not given. There was no evidence why the drug was not given, nor was there any evidence the physician and/or the guardian were informed. Resident #26 Resident #26 required surgical intervention to remove a large growth from her left eyebrow on 6/6/13, by a dermatologist. Documentation revealed this resident refused to have daily wound care performed, but the dermatologist was not informed until seven days later on 6/13/13. Orders were received to remove the dressing and leave the wound open to air. Resident #26 refused to have the dressing removed or any care provided. The dermatologist was not informed of Resident #26's ongoing refusal to care.

Based on review of employee files, facility documents, and interview, the facility failed to ensure a thorough investigation was completed prior to re-hiring a worker with allegations of neglect and failed to ensure staff was educated on the abuse prohibition policies. Findings include: Review of the facility self-reports revealed one certified nursing assistant (CNA-Employee #5) was named in three self-reports: 1. On 9/16/13, the CNA was still in training and failed to use appropriate equipment while transferring a resident, resulting in minor injury to the resident. 2. On 10/5/13, the CNA was seen forcing a resident into the dining room against the resident's wishes. 3. On 1/3/14, the CNA told a resident she did not have time to take him to the bath room, and he should just "go in his brief." The resident reported the allegation to the social worker. The CNA was suspended pending investigation, and then subsequently terminated for the substantiated allegation of neglect. On 1/30/14, the facility's schedules were reviewed and revealed Employee #5 was on the schedule and working at the facility during the survey 1/30/14 -2/10/14. On 1/30/14, the Director of Nurses was interviewed and confirmed CNA-Employee #5 had been re-hired by the new Administrator. On 2/3/14, the personnel file of CNA-Employee #5 was reviewed and revealed two of three job references marked the CNA was ineligible for re-hire at their organizations. On 2/3/14, the CNA-Employee #5 was interviewed and denied the allegations that lead to her termination. The CNA-Employee #5 reported she had been "coerced" into answering affirmatively to the former Director of Nurses (DON) and that the former DON was "out to get her," very aggressive and "...shaking her finger in my (Employee #5's) face." On 2/3/14, the social worker was interviewed and confirmed the resident had told her CNA-Employee #5 had told him to "just go in his brief". The social worker reported the resident's roommate also confirmed the incident. On 2/3/14, the resident (Resident #31) was interviewed and confirmed the incident had happened, although he was unable to name the specific CNA. On 2/3/14, the assistant Director of Nurses (ADON) was interviewed and reported she was present when the former DON had talked with CNA-Employee #5. The ADON reported she did not recall the former DON being overly aggressive with the CNA or shaking her finger in the CNA's face. On 2/3/14, the transporter was interviewed and reported she was standing at the nurses station when the former DON talked with CNA-Employee #5. The transporter reported the former DON told CNA-Employee #5 what Resident #31 had told the social worker. The transporter reported CNA-Employee #5 responded matter of factly, "I told him to go in his brief and I'd be back in a little while to change him." The transporter reported the former DON told the CNA-Employee #5, "You can't tell a resident that. That's considered abuse." The transporter reported the DON then took CNA-Employee #5 behind the nurses station to look at the resident's care directives, and learned he was on a toileting program, and to be taken to the bath room every hour. The transporter reported CNA-Employee #5 responded she didn't know that, and would do better next time. The transporter reported the former DON told the CNA-Employee #5 she needed to clock out and go home that she was suspended pending investigation. The transporter reported the former DON was upset the incident occurred, however, the transporter did not witness the former DON being aggressive or shaking her finger in CNA-Employee #5's face. On 2/4/14, CNA-Employee #20 was interviewed. The CNA-Employee #20 reported she had been the former lead CNA in charge of station I. CNA-Employee #20 reported she was answering call lights and was not at the nurses station when CNA-Employee #5 was interviewed by the former DON. On 2/5/14, licensed practical nurse (LPN-Employee #16) was interviewed and reported she was the former wound care nurse and was at the nurses station when the former DON interviewed CNA-Employee #5. The LPN-Employee #16 reported the former DON asked CNA-Employee #5 if she had told a resident to go to the bathroom in his briefs, and CNA-Employee #5 had answered, "Yes." The LPN-Employee #16 reported the former DON told CNA-Employee #5 to clock out and go home. The LPN-Employee #16 reported she did not witness the former DON shaking her finger in CNA-Employee #5's face. On 2/3/14, the Activities Director was interviewed and reported her observation was CNA-Employee #5 was not sympathetic or kind when interacting with the residents. On 2/3/14, the staff development coordinator (SDC) was interviewed and reported she had recently taken over the hiring of CNAs. The SDC reported she was unaware CNA-Employee #5 had two references that marked her as ineligible for rehire. The SDC reported if she had known that information, CNA-Employee #5 would not have been hired for the CNA training program. On 2/3/14, the Administrator was interviewed and reported after the former Administrator and former DON were terminated and he was hired, he made it known that anyone who was previously terminated could apply to return to employment at the facility. The Administrator reported the investigation he had conducted suggested the former DON may not have been justified in firing CNA-Employee #5. The Administrator reported he did not know about the two previous self-reports filed on CNA-Employee #5. The Administrator reported he did not know two references for CNA-Employee #5 listed her as ineligible for rehire. Abuse interviews An abuse interview was conducted with an evening shift nurse on 2/5/14 at approximately 4:00 PM. This nurse confirmed she had been employed at the facility since 2011, and had received abuse and neglect training within the past year (2013). This nurse could not identify any of the different types of abuse except for "physical" and "verbal." This nurse was asked to identify the five other types of abuse (sexual, mental, seclusion, misappropriation of funds/property or neglect), but could not describe them without extensive prompting by the surveyor. This nurse described seclusion as an act the resident would do to themselves, (self-isolation) not as an act staff would do to resident. When asked what this staff member would do if she saw an act of suspected abuse or neglect, she indicated she would report it to the abuse coordinator and had thought staff had 24 hours to report abuse. This nurse then clarified her comments and indicated abuse needed to be reported immediately. An interview with the Staff Development nurse was conducted directly after this staff interview. The Staff Development nurse confirmed staff should be aware of all seven categories of abuse and neglect. The Staff Development nurse also confirmed staff were to report abuse or neglect immediately. Complaint #NV 048

NAC 632.216 Care of patients; additional authorized duties. 1. A registered nurse shall perform or supervise: (a) The assessment and evaluation of the health of each patient under the care of the registered nurse based on his or her knowledge or understanding of the biological, psychological, social and cultural factors affecting the patient ' s condition; (b) The development of a written plan for the care of each patient under the care of the registered nurse based on the present and predicted needs of the patient, and shall review and revise that plan if necessary; (c) The evaluation of a patient ' s health and the initiation of acts which are necessary to provide adequate care to a patient when needed, giving direct care to a patient, assisting with the care of the patient or delegating the care of the patient to persons qualified to provide that care; (d) Making judgments and decisions regarding the status of a patient and the planning, carrying out, evaluation, and modification of the patient ' s care as needed; (e) The documentation of observations, assessments and responses of patients and the care provided to those patients; and (f) In situations which threaten the life of a patient, acts which are necessary to stabilize the patient ' s condition and prevent more serious complications, performed pursuant to an established policy. 2. A registered nurse may perform: (a) The duties of a circulating nurse or surgical first assistant in an operating room; and (b) Uncomplicated deliveries of infants if: (1) The registered nurse is an advanced practitioner of nursing; and (2) The delivery is performed under the direction of a physician. Nevada Administrative Code (NAC) 632.220 Medication and treatment of [REDACTED]. 1. A registered nurse shall perform or supervise: (a) The verification of an order given for the care of a patient to ensure that it is appropriate and properly authorized and that there are no documented contraindications in carrying out the order; (b) Any act necessary to understand the purpose and effect of medications and treatments and to ensure the competence of the person to whom the administration of medications is delegated; and (c) The initiation of intravenous therapy and the administration of intravenous medication. 2. A registered nurse shall take orders only from a licensed physician, physician assistant, dentist, podiatric physician or advanced practitioner of nursing. A registered nurse may refuse an order if he or she takes appropriate action to ensure the safety of a patient. 3. If a prescription specifies a range of the dosage or frequency for the administration of a medication, a registered nurse may adjust the dosage or frequency of the medication within that range when he or she administers the medication to a patient. Nevada Revised Statues (NRS) 632.0169 "Practice of nursing" defined. "Practice of nursing" means the general observation, [DIAGNOSES REDACTED]. The term does not include acts of medical [DIAGNOSES REDACTED]. NRS 632.017 "Practice of practical nursing" defined. "practice of practical nursing" means the performance of selected acts in the care of the ill, injured or infirm under the direction of a registered professional nurse... NRS 632.018 "Practice of professional nursing" defined. "Practice of professional nursing" means the performance of any act in the observation, care and counsel of the ill, injured or infirm, in the maintenance of health or prevention of illness of others, in the supervision and teaching of other personnel, in the administration of medications and treatments as prescribed by an advanced practitioner of nursing, a licensed physician, a licensed physician assistant... requiring substantial specialized judgment and skill based on knowledge and application of the principles of biological, physical, and social science, but does not include acts of medical [DIAGNOSES REDACTED]. NAC 632.249 Identification by appropriate title required; Identification requirements for telenursing. 1. Each registered nurse, licensed practical nurse, certified nursing assistant, nursing student and nurse certified in an advanced speciality shall identify himself by his appropriate title: (a) When recording information on a record; (b) When introducing himself to a client, patient or prospective patient; and (c) On a name tag which: (1) Includes, at a minimum, his first name and the first initial of his last name, and his title; (2) Is prominently displayed on his clothing; and (3) Is clearly legible from a distance of at least 3 feet." Based on observation, interview, record review and document review, the facility failed: (1) To ensure staff clarified physician orders [REDACTED].# 21); (2) To ensure nursing staff followed physician orders [REDACTED]. (3) To ensure nursing staff followed physician orders [REDACTED]. (4) To ensure complete adequate wound care assessment and follow up care (Residents #7, #19, and #26); (5) To ensure pharmacy recommendations were completed (Resident #15); and (6) To ensure verbal or telephone orders were signed with name and title (Resident #40). Findings include: Resident # 21 Resident #21 was admitted to the facility on [DATE], with a re-admitted s of 7/29/13 and 12/12/13, with [DIAGNOSES REDACTED]. Review of Resident #21's admission orders [REDACTED]. The resident was on [MEDICATION NAME] 500 milligrams (mg) twice a day for a [DIAGNOSES REDACTED]. Review of the MARs for May 2013, June 2013, and July 2013, revealed a FSBS was conducted daily at 8:00 AM through 7/24/13, when the resident was transferred to an acute care hospital. Review of the residents physician orders [REDACTED]. Resident #21 was re-admitted on [DATE]. Review of the resident's admission orders [REDACTED]. The resident continued on [MEDICATION NAME] 500 mg twice a day for diabetes mellitus. Review of the MARs revealed the finger sticks were done for seven days. Review of the October 2013 and November 2013 physician order [REDACTED]. Review of the physician progress notes [REDACTED]. The APN documented "DM-stable" on 9/12/13, 9/19/13, 9/28/13, 10/16/13, and 10/26/13. On 9/12/13, a physician documented the chart was reviewed and "agree with plan." On 11/13/13, the resident was seen by a physician, the physician documented medically stable. On 11/14/13, the resident was seen by a physician assistant (PA) and the documentation was "no change in patient status, continue medications." On 12/8/13, the PA saw the resident, and documented, "no complaints and no s/s (signs/symptoms) of distress." Sometime that same day, the APN saw Resident #21 for altered mental status and lethargy. On 12/9/13 at 12:39 PM, the APN documented the resident had increased respirations of 32 (normal adult rate is 12-20), "very dry oral mucosa", "dry gangrene right second toe" and a blood sugar of 692. The APN wrote "severe dehydration, acidosis, uncontrolled DM, and leukocytosis. The resident was transferred to an acute care hospital. Review of Resident #21's record revealed no vital signs were documented since 11/17/13. There was no documentation of FSBS. No labs had been drawn on the resident since his July 2013 hospitalization . On 2/4/14, the Director of Nurses (DON) reviewed Resident #21's record and confirmed there should have been vital signs recorded at least weekly. The DON confirmed the FSBS order should have been clarified. Review of Resident #21's discharge summary from the acute care hospital revealed the resident was admitted for "hyperosmolar nonketotic state, there may be a component of diabetic ketoacidosis." The resident was aggressively rehydrated with intravenous fluids, treated with sliding scale insulin coverage. The resident was admitted to the hospital for four days, transferred back to the facility on [DATE]. The following day, 12/13/14, the resident was transferred back to an acute care facility, for "right lower extremity limb threat." The resident required an above the knee amputation of the right leg. On 2/11/14, Resident #21's wife was interviewed and reported she did not know the facility had not been doing finger stick blood sugars, as no one had advised her of the change in treatment plan. Resident #21's wife reported she came to the facility daily to see her husband and attended all the care plan meetings. Resident #21's wife reported she had performed the finger sticks for her husband for years. Resident #21's wife reported the surgeon advised her if the limb threat had been identified earlier, most of the leg may have been able to be saved. Resident #37 On 2/3/14 at approximately 8:30 AM, an licensed practical nurse (LPN- Employee #17) was observed giving medications to Resident #37. LPN-Employee #17 was observed to crush the resident's medications, including the [MEDICATION NAME] coated aspirin. On 2/3/14 at approximately 8:35 AM, LPN-Employee #17 was interviewed and asked about the availability of a "do not crush" list. LPN-Employee #17 reported there was a list and he had not considered that [MEDICATION NAME] coated aspirin should not be crushed. Review of Resident #37's record revealed the order was for aspirin 162 milligrams. The order did not specify [MEDICATION NAME] coated aspirin. On 2/3/14, the Director of Nurses (DON) was interviewed and reported the nurses were to follow the physician orders. In this case, the DON reported the nurse should have crushed regular aspirin for Resident #37. Nurse Signatures - Resident #40 Record review revealed Resident #40's dosage for the drug [MEDICATION NAME] was changed by the physician on 1/10/14. The nurse who transcribed the order did not identify her name or title. The nurse only used her initials to indicate the order was received and did not date or identify the time of transcription. The Director of Nurses was interviewed on the morning of 2/5/14, and confirmed the nurse was required to place her signature and title to indicate the order was transcribed. Review of documentation in the clinical record, nursing notes and physician orders [REDACTED]. 1) Employee #12, a registered nurse did not include her title with her signature. 2) Employee #28, a licensed practical nurse, only used her initials following her entries in the clinical record. Nursing staff failed to perform appropriate wound appearance documentation or ensure appropriate interventions for care Review of the facility policies revealed: Skin Integrity BHC-CSM 9.1 effective 2/2000 describes the "facility will have a systematic approach and monitoring process for evaluating and documenting skin integrity in an effort to maintain the residents' optimal level of skin integrity" "2. The nurse completes the skin integrity evaluation form quarterly or when there is a significant change in condition." "3. The nurse completes a weekly visual skin inspection." "4. The resident's skin...is inspected daily when activities of daily living are performed. Changes in the resident's skin are reported to the nurse." Resident #7 Resident #7 has been a resident for two years, with primary [DIAGNOSES REDACTED]. Review of the pressure ulcer risk scoring tool ( Braden Scale) indicated Resident #7 was scored 13 consistently for the past two years. A score of 12 or less represented a high risk to develop pressure sores. Review of the minimum data set collections for 2013 revealed this resident was at risk for pressure ulcers, but had no pressure ulcers through 2013 until a stage four pressure ulcer was identified as being present in November 2013. Clinical record review revealed the stage four pressure ulcer was identified on 10/12/13. The following events were transcribed. 1) According to documentation, Resident #7 had a weekly skin assessment performed on 9/28/13, and did not have another skin assessment performed until 10/26/13. There was no weekly skin assessments performed on 10/5/13 and 10/12/13. Documentation indicated the resident refused these assessments. There was no skin assessments documented on 10/19/13, or any indication why this had not been performed. Review of the clinical nursing notes for Resident #7 revealed the following: 10/12/13: "Resident has an open sore at left antecubital." There was no evidence of any detailed assessment or measurement of the wound, or a wound care sheet initiated. An order was received for wound care. 10/15/13: The resident was taken to a wound clinic for evaluation and treatment, and new orders were received. It was determined this was a stage four pressure ulcer and the tendon was exposed. 10/16/13: A interdisciplinary note written on 10/16/13, indicated the wound on Resident #7's antecubital area was 4.5 centimeters (cm) long by 3 cm wide and 0.2 cm deep. (1.75 inches long, 1.25 inches wide and one quarter inch deep). 10/24/13: A late entry was written on this date to indicate that on 10/8/13, the physician was informed "necessity for resident's left elbow, lateral redness and open area to be assessed." There was no indication the physician or designee assessed this wound until 10/12/13. The facility indicated nursing staff informed the physician of the occurrence of Resident #7's wound on 10/8/13, per the use of a communication book entry, but could not provide this evidence. Clinical record revealed the following documentation by the advanced practice registered nurse (APN) regarding Resident #7: 10/2/13, no concerns with skin issues. 10/12/13, an open sore on Resident #7's left antecubital (inner elbow) area. The facility could not provide any evidence of any thorough assessment of the left elbow wound at the time of initial onset (10/8/13) or 10/12/13 by the nursing staff. There was no wound assessment or skin assessment sheets for October. A wound/skin evaluation form was initiated on 11/12/13, to describe the condition of the stage four antecubital wound, approximately 34 days after it was first identified. This sheet only included two wound assessments: 11/12/13 and 11/18/13. The facility could not provide any evidence that nursing staff followed up in reporting the wound to the physician between 10/8/13 - 10/12/13. Resident #19 Resident #19 was a [AGE] year old resident who has resided in the facility since 2008. Her primary [DIAGNOSES REDACTED]. Review of her record revealed she required total assistance and was a high risk for pressure ulcers. On 12/15/13, (a Sunday) a Stage two open area pressure ulcer was identified on her buttocks (right buttock/coccyx area) during care. Wound care orders were obtained for wound care every three days by the registered nurse. On 12/17/13, a wound/skin evaluation form was created by the wound care nurse who documented the length and width, but did not describe the color of the area or the surrounding tissue or any depth. On 12/24/13, the wound care nurse did not identify the stage of the pressure ulcer or the condition of the surrounding tissue area. On 12/31/13, the wound care nurse did not describe the wound at all, did not take measurements. She only documented the type of dressing. Resident #26 Resident #26 has resided in the facility since 2008, with [DIAGNOSES REDACTED]. Review of the doctor progress notes revealed an entry on 1/2/13, that a "horny lesion was present over the resident's left eyebrow." An entry on 8/27/13, by the advanced practice nurse (APN) revealed the area over the left eyebrow has deteriorated, "...very large [MEDICAL CONDITION] above left eye that involves area size of tennis ball and began to occlude vision, raw and erosive." A report on 10/25/13, revealed Resident #26's wound over the left eye became visible and was infected with maggots. A description in the facility report was this lesion extended from the left eye, side of face and back of head. The resident was sent to the emergency room for further evaluation and treatment. Wound evaluation sheets revealed there was no further description of this wound as far as size except that the resident refused the wound to be measured. Wound care forms revealed Resident #26 consistently refused wound care to the area, but there was no evidence that any visual observations of the wound dressing were performed, attempts to ensure no further maggot infestation or descriptions of any drainage, odor, swelling or pain were performed. The next entry was dated 12/10/13, and described the wound on the left face area was yellow/black in color with tan, foul smelling drainage. There was no visual measurement or other description of the wound. Resident # 11 Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/3/14, Resident #11's medical records were reviewed. Review of Resident #11's Nurse's Notes indicated the resident was sent to the emergency room (ER) on 9/20/13, to be evaluated and for the treatment of [REDACTED]. The emergency room discharge instructions, dated 9/20/13 at 1:20 PM indicated the following: 1) scrotum inflammation, 2) clean scrotum with [MEDICATION NAME] soap and water twice daily, dry thoroughly and apply Gold Bond Powder to the scrotum to keep area completely dry, 3) change wet or soiled diapers immediately, 4) follow up with Dr. (urologist) in 5 to 7 days for a recheck, 5) return to ER sooner if any new problems develop before you see urologist. There was no evidence that the follow up appointment with the urologist, had been made. On 2/5/14 at 8:15 AM the record review findings were discussed with the Director of Nursing (DON - Employee #2). The DON confirmed the follow up visit with the urologist had not been made. Resident #15 Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's medications included [MEDICATION NAME] 45 milliters to be administered by mouth every six hours (total of four doses per day), for the treatment of [REDACTED]. Note: Elevated ammonia levels, which are a result of hepatic [MEDICAL CONDITION], is commonly treated with the administration of [MEDICATION NAME]. [MEDICATION NAME] is used to decrease elevated blood ammonia levels and to maintain ammonia levels within acceptable parameters on an ongoing bases. Early signs of an elevated ammonia level include slight personality changes (disorientation, forgetfulness, slurred speech) and a slight tremor. Symptoms can progress to a comatose state if left untreated. Review of Resident #15's medical records revealed the resident had a history of [REDACTED]. On the afternoon of 2/3/14, during a group meeting to discuss concerns, Resident #15 indicated she had not received her medication, [MEDICATION NAME], in several days. The resident indicated she could tell her ammonia levels were starting to rise. After the resident left the meeting two other residents that had attended the meeting, indicated they could see a difference in Resident #15 behavior and thought it might be due to her not receiving her medication. Following the meeting, Resident #15's medication administration records (MARs) for January 2014 and February 2014, were reviewed. Between Thursday January 30, 2014 and Monday February 3, 2014, there were a total 18 doses of [MEDICATION NAME] that were not administered to the resident. It was documented the doses had not been given due to being out of the [MEDICATION NAME]. On Saturday 2/1/14 at 4:00 PM and 8:00 PM, it was documented: "[MEDICATION NAME] reordered at pharmacy via fax." On Sunday 2/2/14, it was document for the 4:00 PM and 8:00 PM doses: "[MEDICATION NAME] out, pharm (pharmacy) will send on Monday." On Monday 2/3/14 at 8:50 AM, it was documented: "[MEDICATION NAME] not arrived from Rx (pharmacy) - to fax re-Fax x 2." On 2/4/14, review of Resident #15's medical record failed to provide evidence that the physician was notified of the missed doses of medications ([MEDICATION NAME]). On the afternoon of 2/4/14, the findings for Resident #15's medication and medication record were reviewed with the Director of Nursing (DON - Employee #2). The DON confirmed the physician had not been notified and indicated the physician should have been notified right away of the missed doses. The DON indicated there were provisions in place for obtaining refills on the weekends. The DON indicated she was aware of the resident's history of developing increased ammonia levels and related falls. Review of the facility's policy titled, "1.0 Providing Pharmacy Products and Services," with the effective date of 12/1/07, indicated the following: - Procedure: 1. Pharmacy will provide the Facility with a facility-specific information sheet that details how the Facility staff can contact the Pharmacy twenty four (24) hours a day, seven (7) days a week. (See Appendix 1-Pharmacy Services Overview), 4.1.1 If a drug cannot be substituted, Facility staff soul ask the prescriber if the drug therapy can be initiated the next morning. If it is possible to initiate the drug therapy the next morning, Facility staff should document its conversation with the prescriber and include the start time in the order. 4.1.2 If a drug is considered essential and cannot be substituted or delay, Facility staff should contact the emergency number provided by the Pharmacy... Review of the facility's policy titled, "2.0 Resident Medication Rights," with the effective date of 12/1/07, indicated the following: - Procedure: 1. Facility should notify physician a resident's refusal of treatment... 2. Facility should notify Prescriber of a resident's refusal of medications/treatments for periods greater than twenty four (24) hours. Facility should notify Prescriber immediately if the refused drug could affect the health or safety of the resident. 3. Facility should document the effect of refused drugs, treatments or doses in the Resident's clinical record. Review of a staff training titled, "Medication Treatment Unavailable or Refusals," presented to staff on 1/13/14, outlined the following: - It is not acceptable to just not give a medication because your cannot find it or it is unavailable from the pharmacy. - 1. If a medication has not arrived from pharmacy in a timely manner and your are unable to administer the medication when it is ordered, you must notify pharmacy immediately to get that medication delivered and notify the medical provider for further instruction. This must be documented. Also please notify the DNS (Director of Nursing Services) or ED (Executive Director (Administrator)) if there is any further problems with this medication delivery. - 3. Refusals cannot just be circled. They also have to be charted on the back of the MAR (Medication Administration Record) of why they refused and what you did to educate or encourage them for compliance with the med/tx (treatment) plan.

Based on record review and interview the facility failed to ensure: (1) Resident with dental pain received follow up care (Resident #9); (2) Residents were bathed regularly (Residents #7, #19, and #26); (3) Resident with [MEDICAL CONDITION] received care (Resident #26); (4) Resident received medications as ordered (Resident #15); and (5) Resident received appropriate pericare and follow up urology appointment (Resident # 11). Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was Spanish speaking only. Review of Resident #9's record revealed the resident complained frequently of tooth pain. Review of the dental consultations revealed the resident was seen on 6/18/13, and the dentist recommended antibiotics and an extraction of tooth #21. On 7/1/13, the resident had tooth #21 extracted. On 8/21/13, the dentist recommended waiting eight weeks for the gums to heal, then have additional extractions of teeth #24 and #25. The dentist noted the resident would require pre-authorization from her insurance. The resident was seen on 12/5/13, for dental pain and prescribed antibiotics. The dentist documented, "...we will wait until we get okay from (insurance)." On 1/30/14, the resident was interviewed in Spanish by the surveyor. The resident indicated she had difficulty biting and chewing food properly due to dental pain and discomfort. The resident had not been offered an alternative diet to accommodate her dental discomfort. On 1/30/14, the social worker was interviewed and reported she had made a referral to the transportation assistant to make Resident #9 an appointment. The social worker was unsure how long the pre-authorization took, but was certain someone was working on it. The Director of Nurses was interviewed and confirmed Resident #9 had not had a follow up dental appointment as of 2/3/14. An appointment was made for 2/7/14 for the resident to see the dentist. On 2/6/14 at 1:00 PM, Resident #9, her daughter and an interpreter were interviewed. Resident #9 reported the dental pain had been worse since January. The resident reported the pain was a "10" on a scale of 1 - 10, with 10 being the worst pain. The resident reported [MEDICATION NAME] and Tylenol upset her stomach, so she would only take one Tylenol for the pain. Resident #9's daughter reported she had called the facility three times in January to request a dental appointment for her mother. Resident #26 Resident #26 was identified as having [MEDICAL CONDITION] tumor located above her left eye. Resident #26 had surgery to remove the tumor. Review of the physician orders [REDACTED]. Wound care treatment records revealed staff did not perform this care because the resident refused care. During the months of August, September and October of 2013, the resident received no wound care. Nursing documentation indicated the resident refused care, but there was no evidence of changes to Resident #26's approaches, changes in orders, or increased visual assessment and monitoring of the left eye tumor to indicate possible deterioration of the tumor. This tumor was identified as having maggots present in the wound on 10/24/13. A wound/skin evaluation form was created on 10/24/13, for Resident #26's left eyebrow wound. The size at this time was nine centimeters (cm) (approximately 3.5 inches) in diameter and raised two cm (approximately 3/4 inches) and contained a five cm (2 inch) center of dead tissue. This wound had moderate serous-sanguinous (watery/bloody) drainage. This form also indicated the resident did not want to have staff touch the wound due to pain. There was no evidence of further data collection/assessment of this wound until 12/10/13. At this time the wound was yellow/black with tan, foul smelling drainage. There was no size described, either visual description or measurement documented. The wound care evaluations for the rest of December 2013, and January 2014, indicated the resident refused to allow measurements. Failure to provide adequate bathing/showers to residents. Review of the activity of daily living records (ADLs) for August, September, October and November 2013, revealed that in these four months Resident #26 received only eight showers/bathing. Resident #26 received no showers the month of December 2013. There were no evidence the interdisciplinary team evaluated options regarding Resident #26's ongoing refusal to allow care or (more importantly) were any methods effective. Resident #7 A review of activities of daily living records (ADLs) for September, October, November and December indicated Resident #7 received only eight showers/bathing during a four month period. Resident #19 Resident #19 has resided in the facility since 2008, and was [AGE] years old . The primary [DIAGNOSES REDACTED]. Resident #19 was incontinent of both bladder and bowel. Review of care plans, medication administration records and behaviors monitoring revealed Resident #19 did not refuse medications, care or have any behaviors other than decreased appetite related to depression Review of the ADL sheets for November 2013, revealed Resident #19 received four showers/bathing in 30 days, only received two showers during December 2013, and four showers in January 2014. Review of the November, December and January ADL sheets revealed Resident #19 did not receive a shower from 11/28/13 to 12/23/13, a period of 25 days. Review of the facility policies revealed: Skin Integrity BHC-CSM 9.1, effective 2/2000 describes the "facility will have a systemic approach and monitoring process for evaluating and documenting skin integrity in an effort to maintain the residents' optimal level of skin integrity" "2. The nurse completes the skin integrity evaluation form quarterly or when there is a significant change in condition." "3. The nurse completes a weekly visual skin inspection." "4. The resident's skin...is inspected daily when activities of daily living are performed. Changes in the resident's skin are reported to the nurse." A request for facility policies regarding providing showers or bed baths to residents were requested, but the facility could not provide any policies. The facility was asked to provide evidence these residents were bathed/showered on a regular basis, or that the charge nurses were informed these residents were not able to be provided baths/showers. The facility was not able to provide any of this information. Resident # 11 Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Prior to the survey, the facility's self report dated 9/11/13, for Resident #11 was reviewed. The report indicated the resident had reported between the dates of 8/28/13 and 9/11/13, involving the hours between 6:00 AM and 7:00 PM, three certified nursing assistants (CNAs) failed to provide the resident with adequate or proper peri care on a consistent basis. The report indicated an interview was conducted with all three of the CNAs, and the CNAs indicated "...they could/should be more thoroughly cleanses resident and applying creams." The report indicated the following actions were taken: "All 3 CNAs received counseling and reminded of importance of quality resident care." There was no evidence in the report to indicate that the CNAs had been retrained on the facility's policy and procedure on peri care, or that the CNAs technique and/or skills in delivering peri care were observed or monitored. On 1/30/14 at 7:40 AM, an interview was conducted with Resident #11. The resident indicated he recalled the 9/11/13 incident when he had reported the aides were not cleaning and/or giving him adequate peri care. The resident indicated one aide was not washing him off between changing his soiled brief, while other aides were not cleaning off the old peri cream, but were just applying more cream on top of the existing cream when they changed him. The resident also recalled going to the emergency roiagnom on [DATE], and indicated when the doctor examined him the doctor indicated he was going to report the situation as he (doctor) thought the resident's condition was a result of neglect. On 2/3/14, Resident #11's medical records were reviewed. - Progress Notes dated 8/31/13, by the physician's assistant indicated the following: 1) resident was complaining of pain at the scrotum with a pain level of six to ten, 2) severe [DIAGNOSES REDACTED] (redness) with skin breakdown at the scrotum, 3) scrotal rash, [MEDICATION NAME] not effective start [MEDICATION NAME] cream twice a day for ten days, change diaper frequently. - A Progress Note dated 9/6/13, by the physician, indicated the following: 1) scrotal [DIAGNOSES REDACTED], skin tenderness, skin impairment, 2) scrotal [MEDICAL CONDITION], and 3) scrotal [MEDICAL CONDITION] continue with topical treatment avoid scrubbing skin. - Another Progress Note dated 9/25/13, by the practitioner indicated the following: 1) increase [DIAGNOSES REDACTED] and tenderness to scrotum, 2) concerned about [MEDICAL CONDITION] 3) sending to ER for evaluation, 4) needs urinalysis and lab work? start antibiotic. Resident #11's care plans failed to provide evidence that a care plan had been developed to address the scrotal irritation and skin breakdown. Resident #11's Nurse's Notes indicated the resident was sent to the emergency room (ER) on 9/20/13, to be evaluated and for the treatment of [REDACTED]. The emergency room discharge instructions, dated 9/20/13 at 1:20 PM, indicated the following: 1) scrotum inflammation, 2) clean scrotum with [MEDICATION NAME] soap and water twice daily, dry thoroughly and apply Gold Bond Powder to the scrotum to keep area completely dry, 3) change wet or soiled diapers immediately, 4) follow up with Dr. (urologist) in 5 to 7 days for a recheck, 5) return to ER sooner if any new problems develop before you see urologist. On the copy of the discharge instructions, there was an added hand written note by the facility staff dated 9/21/13, which indicated: 1) per (practitioner) change gold bond powder to peri guard (cream), and the words Gold Bond Powder were crossed through with a single line. There was no evidence in the resident's record that the complete documentation of the ER visit had been obtained by the facility. There was also no evidence that the follow-up appointment with the urologist, had been made. Additional Nurse's Notes indicated the following: - 9/21/13 2:00 PM, Practitioner made aware resident came back from the ER yesterday with order to clean scrotum with soap and water, pat dry, apply peri guard twice a day, mild redness noted in scrotum area ... - 9/22/13 1:00 PM, peri care given, cleaned with soap and water pat dried and applied peri guard as ordered. Scrotum and peri are still red, complains of discomfort to scrotum upon palpation/touch.... - 9/23/13 1:15 PM, cleaned peri area and scrotum with soap and water, pat dried and applied peri guard as ordered, peri area less redness noticed today. Scrotum remains enlarged. Review of Resident #11's weekly skin assessments for the period of July 2013 through December 2013, failed to identify concerns related to the condition of the scrotum. Although, the review of Resident #11's ADL Flowsheets for the period of September 2013 to January 2014, indicated the resident was incontinent of bowel and bladder. On 2/5/14, in a random interview with one unidentified nursing assistant, the assistant indicated the resident was continent and could let you know when he needed to go to the bathroom. On 2/5/14 at 8:15 AM, the self report and record review findings were discussed with the Director of Nursing (DON - Employee #2). The DON confirmed the facility had not obtained the complete documentation of Resident #11's 9/20/13 ER visit, and a follow up visit with the urologist had not been made. The DON confirmed a care plan had not been developed and agreed the weekly skin checks were either not completed or were inadequate in the documentation of the Resident #11's situation. On 2/5/14 at 9:00 AM, the complete documentation of Resident #11's ER visit was obtained and reviewed. The documentation revealed the following: - History of Present Illness: ... presents with complaints of persistent [DIAGNOSES REDACTED] and tenderness to the scrotum over the past 4-5 weeks... has been seen by several practitioners in the nursing home ... and has been treated with various ointments... not getting any better... currently having barrier cream applied to the area... denies any other medical complaint other than the persistent scrotal inflammation... states at the nursing home where he resides, often times he has great difficulty in getting his diaper changed due to the workload of the nursing staff... states at times he was forced to urinate in his diaper due to their inability to assist him to the commode... - Physical Examination: ... Scrotum is [DIAGNOSES REDACTED]tous and tender to palpation... no evidence of [MEDICAL CONDITION] to this area... - Hospital Course: I (doctor) did discuss the case with (name), on call urology. He suggested a course of daily soap and water, cleaning of the scrotum followed by application of Gold Bond powder to keep the area completely dry. Discontinue all ointments or creams. This care was given to the patient in the Emergency Department... -Final Diagnosis: [REDACTED]. Resident #15 Resident #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's medications included [MEDICATION NAME] 45 milliters to be administered by mouth every six hours (total of four doses per day), for the treatment of [REDACTED]. Note: Elevated ammonia levels, which are a result of hepatic [MEDICAL CONDITION], is commonly treated with the administration of [MEDICATION NAME]. [MEDICATION NAME] is used to decrease elevated blood ammonia levels and to maintain ammonia levels within acceptable parameters on an ongoing bases. Early signs of an elevated ammonia level include slight personality changes (disorientation, forgetfulness, slurred speech) and a slight tremor. Symptoms can progress to a comatose state if left untreated. Review of Resident #15's medical records revealed the resident had a history of [REDACTED]. There were several care plans for "Risk for falls secondary to: confusion, hepatic encephlopathy, increased ammonia levels." Only one of these care plans addressed lab work to check ammonia levels under interventions. Another care plan indicated the resident gets confused when her ammonia levels are high, the goal for this care plan indicated the resident would like to move into an assisted living; interventions included activities will reassure the resident when she feels she cannot do anything, resident can become very insecure and needs to be told she's doing fine-the date for this care plan was dated 10/1/13. There was no care plan that specifically addressed the resident's encepthalopathy, associated medications or the need to closely monitor the ammonia levels to prevent confusion, falls, etc. On the afternoon of 2/3/14, during a group meeting to discuss concerns, Resident #15 indicated she had not received her medication, [MEDICATION NAME], in several days. The resident indicated she could tell when her ammonia levels were starting to rise. After the resident left the meeting, two other residents that had attended the meeting, indicated they could see a difference in Resident #15 behavior and thought it might be due to her not receiving her medication. Following the meeting, Resident #15's medication administration records (MARs) for January 2014 and February 2014, were reviewed. Between Thursday January 30, 2014 and Monday February 3, 2014, there were a total 18 doses of [MEDICATION NAME] that were not administered to the resident. It was documented the doses had not been given due to being out of the [MEDICATION NAME]. On Saturday, 2/1/14 at 4:00 PM and 8:00 PM, it was documented: "[MEDICATION NAME] reordered at pharmacy via fax." On Sunday 2/2/14, it was document for the 4:00 PM and 8:00 PM doses: "[MEDICATION NAME] out, pharm (pharmacy) will send on Monday." On Monday 2/3/14 at 8:50 AM, it was documented: "[MEDICATION NAME] not arrived from Rx (pharmacy) - to fax re-Fax x 2." On 2/4/14, review of Resident #15's medical record failed to provide evidence that the physician was notified of the missed doses of medications ([MEDICATION NAME]). On the afternoon of 2/4/14, the findings for Resident #15's medication and medication record were reviewed with the Director of Nursing (DON - Employee #2). The DON confirmed the physician had not been notified and indicated the physician should have been notified right away of the missed doses. The DON indicated there were provisions in place for obtaining refills on the weekends. The DON indicated she was aware of the resident's history of developing increased ammonia levels and related falls. Review of the facility's policy titled, "1.0 Providing Pharmacy Products and Services," with the effective date of 12/1/07, indicated the following: - Procedure: 1. Pharmacy will provide the Facility with a facility-specific information sheet that details how the Facility staff can contact the Pharmacy twenty four (24) hours a day, seven (7) days a week. (See Appendix1-Pharmacy Services Overview), 4.1.1 If a drug cannot be substituted, Facility staff soul ask the prescriber if the drug therapy can be initiated the next morning. If it is possible to initiate the drug therapy the next morning, Facility staff should document its conversation with the prescriber and include the start time in the order. 4.1.2 If a drug is considered essential and cannot be substituted or delay, Facility staff should contact the emergency number provided by the Pharmacy... Review of the facility's policy titled, "2.0 Resident Medication Rights," with the effective date of 12/1/07, indicated the following: - Procedure: 1. Facility should notify physician a resident's refusal of treatment... 2. Facility should notify Prescriber of a resident's refusal of medications/treatments for periods greater than twenty four (24) hours. Facility should notify Prescriber immediately if the refused drug could affect the health or safety of the resident. 3. Facility should document the effect of refused drugs, treatments or doses in the Resident's clinical record. Review of a staff training titled, "Medication Treatment Unavailable or Refusals," presented to staff on 1/13/14, outlined the following: - It is not acceptable to just not give a medication because your cannot find it or it is unavailable from the pharmacy. - 1. If a medication has not arrived from pharmacy in a timely manner and your are unable to administer the medication when it is ordered, you must notify pharmacy immediately to get that medication delivered and notify the medical provider for further instruction. This must be documented. Also please notify the DNS (Director of Nursing Services) or ED (Executive Director (Administrator)) if there is any further problems with this medication delivery. - 3. Refusals cannot just be circled. They also have to be charted on the back of the MAR (Medication Administration Record) of why they refused and what you did to educate or encourage them for compliance with the med/tx (treatment) plan.

Based on clinical record review, interview, and policies review, the facility failed to ensure one of 24 sampled residents did not develop a pressure ulcer (Resident #7). Findings include: Resident #7 Resident #7 has been a resident for two years, with primary [DIAGNOSES REDACTED]. Resident #7's responsible party was a state appointed guardian. Review of the resident's condition indicated she required maximum assistance for all activities of daily living. Review of the pressure ulcer risk scoring tool ( Braden Scale) indicated Resident #7 was scored 13 consistently for the past two years. A score of 12 or less represented a high risk to develop pressure sores. Review of the minimum data set collections for 2013 revealed this resident was at risk for pressure ulcers, but had no pressure ulcers through 2013 until what appeared to be a sudden onset, stage four pressure ulcer identified as being present in November 2013. Clinical record review revealed the stage four pressure ulcer was identified on 10/12/13. The following events were transcribed. 1) According to documentation, Resident #7 had a weekly skin assessment performed on 9/28/13, and did not have another skin assessment performed until 10/26/13. There was no weekly skin assessments performed on 10/5/13 and 10/12/13. Documentation indicated the resident refused these assessments. There was no skin assessments documented on 10/19/13 or any indication why this had not been performed. Review of the clinical nursing notes for Resident #7 revealed the following: 9/19/13: The nursing aide (CNA) reported bruising and discoloration on the resident's right elbow. Behaviors had been observed of the resident "flailing arms and hands in the air and sometimes hitting table." Care plan was updated and elbow pads were to be used. 9/29/13: The CNA reported bruising of Resident #7's lower right leg. Derma savers (skin protectors) were instituted to protect legs. 10/12/13: "Resident has an open sore at left antecubital." This entry was signed by Employee #12, who was a registered nurse. There was no evidence of any detailed assessment or measurement of the wound or a wound care sheet initiated. An order was received for wound care. No skin assessment was completed. There was no evidence the wound care was initiated. 10/15/13: The resident was taken to a wound clinic for evaluation and treatment and new orders were received. It was determined this was a stage four pressure ulcer and the tendon was exposed. 10/16/13: An X-ray of the left elbow was performed to rule out osteo[DIAGNOSES REDACTED]. 10/17/13; Occupational therapy assessed Resident #7 regarding contracture management of the left elbow related to the stage four wound. 10/24/13: A late entry was written on this date to indicate that on 10/8/13, the physician was informed, "...necessity for resident's left elbow, lateral redness and open area to be assessed." There was no indication the physician or designee assessed this wound until 10/12/13. The nursing staff indicated this was entered into the communication book for the physician on 10/8/13. However the nursing staff also confirmed the communication record entries were discarded, and the facility could not provide any evidence the physician was informed on 10/8/13. A interdisciplinary note written by a registered nurse on 10/16/13, indicated the wound on Resident #7's antecubital area was 4.5 centimeters (cm) long by 3 cm wide and 0.2 cm deep (1.75 inches long, 1.25 inches wide and one quarter inch deep). An interdisciplinary note written on 1/13/14 indicated the stage four pressure ulcer was now 0.5 cm by 0.3. cm by 0.0 cm (one quarter inch by one eight inch and no depth). No redness or drainage. This note also indicated that Resident #7 had a stage two pressure ulcer on her coccyx. The facility could not provide any evidence of any thorough assessment of the left elbow wound, no wound assessment or skin assessment sheets for October. A wound/skin evaluation form was initiated on 11/12/13, to describe the condition of the stage four antecubital wound, approximately 34 days after it was first identified. This sheet only included two wound assessments: 11/12/13 and 11/18/13. Clinical record revealed the following documentation by the advanced practice registered nurse (APN): 10/2/13, no concerns with skin issues. 10/12/13, an open sore on Resident #7's left antecubital (inner elbow) area. 10/17/13, an elbow wound "most like a cut, not an ulcer." 10/26/13, the wound was identified as an "ulcer" approximately the size of a quarter and the tendon was visible. The goal was to keep the tendon moist to "prevent it from decaying." 11/1/13, the left antecubital wound has doubled in size, was now infected and the resident would be started on an antibiotic. 11/10/13, the wound is improved, the tendon is still exposed, the infection has resolved. On 10/15/13, Resident #7's antecubital wound was evaluated at a wound clinic and determined to be a stage four pressure ulcer. Wound care was ordered to be performed daily. Review of the care plans revealed no specific interventions related to the presence of the contractures and the need for elbow pads (possibly causing an increased risk for pressure sore development in the antecubital area). The care plans were vague such as, "actual infection related to wound infection," but did not specify where this wound was, or what specific interventions for Resident #7 would be required. There was no evidence of how often the elbow pads were left on or whether their placement was checked daily to ensure proper placement. Review of the facility policies revealed Skin Integrity BHC-CSM 9.1 effective 2/2000 describes the "facility will have a systematic approach and monitoring process for evaluating and documenting skin integrity in an effort to maintain the residents' optimal level of skin integrity" "2. The nurse completes the skin integrity evaluation form quarterly or when there is a significant change in condition." "3. The nurse completes a weekly visual skin inspection." "4. The resident's skin...is inspected daily when activities of daily living are performed. Changes in the resident's skin are reported to the nurse." Review of all the data provided resulted in the concern that Resident #7 was not provided the appropriate daily care and monitoring to ensure proper placement of the elbow pads. Subsequently, the presence of the contractures, evidence that no skin assessments were completed even after a wound was identified, lack of wound assessment and timely intervention, and possibly no showers for extended periods of time resulted in the development of the stage four ulcer.

Based on record review, interview, review of facility documentation, and observation, the facility failed to adequately supervise the residents. (Residents #24, #32, #38, #1, and #23) or ensure treatment cart supplies were secured. Findings include: Resident #24 Resident #24 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #24 was a resident of Station III, a secured dementia unit. Review of Resident #24's record revealed Resident #24 was unable to ambulate, even with assistance. The resident was total assist for transferring, dressing, eating, hygiene, and bathing. Review of the physician progress notes [REDACTED]. She is requiring increasing amounts of assistance as she does not seem to comprehend the function of tools and is not very effective at feeding herself anymore either." The Advanced Practitioner of Nursing documented the resident had a "fixed expression, nonverbal, but occasional sounds." Review of Resident #24's nurses notes revealed on 1/7/14, the resident was found with bleeding and facial trauma. The resident was transferred to the emergency department and the sheriff was called to the facility. Review of the facility's investigation revealed, "Investigation was begun immediately and it was noted that Resident #24 had lotion smeared on her face. There was also a lotion bottle in her bed. The lotion bottle had a small amount of blood on it... sent to emergency room . She received sutures to the laceration on her face. All other residents were checked to see if they had any injuries...The police were called and they posited that the resident fell and hit her head on the nightstand. Resident #24 does not have the ability to move on her own and requires the assist of two people for mobility. On 1/8/14, Resident #23 was in the dining room... and it was noted that she had what appeared to be blood splatters on the top she wore to bed the night before. Resident #23 also had a new bruise to the top of her right hand. Her hands were clean. An assessment of Resident #23 did not reveal any injury to her that would result in blood splatters on her clothes. ...Resident #23 was placed on 1:1 status for the duration of her stay in this center. Neither resident was able to discuss what happened... A review of Resident #23's chart indicates a history of aggressive behaviors (4/12/13, 6/2/13, 8/7/13) and because of the blood splatters on her clothes, it is suspected that Resident #23 entered Resident #24's room and attempted to put lotion on her face." Review of the facility floor plan revealed the Station III unit was an "H" shape. The nurses station was located at the inner cross bar of the H. Resident #24's room was at the bottom leg of the H. Resident #23's room was located diagonally across the hall from Resident #24's room. Review of the nurses station revealed a camera monitor of the far hall (the lower cross bar of the H). The monitor was able to view from the fire extinguisher outside of Resident #24's room and down the rest of the hall, but did not capture the door to Resident #24's room. On 2/5/14, the certified nursing assistants (CNAs) who worked on 1/7/14 were interviewed. CNA-Employee #7 reported Resident #24 required total assistance with all her activities of daily living, was basically non-verbal, and was laid down after dinner. CNA-Employee #7 reported the CNAs went to dinner in 15 minute increments to have two CNAs remain on the floor. CNA-Employee #7 reported when they were finished with their dinner breaks, they began making their evening rounds. CNA-Employee #7 reported she was working with CNA-Employee # 23 and they started on the back hall. When they came to Resident #24's room, CNA-Employee #7 reported everything seemed fine until they turned the light on. CNA-Employee #7 reported Resident #24 was laying in her bed and had blood on her face. The CNAs immediately called for the nurse. On 2/5/14, the licensed practical nurse (LPN-Employee # 24) was interviewed and reported when she entered Resident #24's room on 1/7/14, she told the CNAs in the room not to touch anything. LPN-Employee #24 reported she called the Director of Nurses, the family, the physician, and the sheriff. LPN-Employee #24 reported when she first arrived on the unit, she ensured the sound of the camera monitor was turned up. LPN-Employee #24 reported she had been sitting at the desk on 1/7/14, prior to Resident #24 being found with the facial trauma, and had heard no sounds coming from that hall. LPN-Employee #24 reported it was very quiet that night. On 2/3/14, the Director of Nurses (DON) was interviewed and asked why Resident #24 remained on Station III when it was determined the resident was immobile and no longer a wander risk? The DON reported she had reviewed the record and did not know why the resident had remained on the locked unit. The DON provided a memo, "Wandering Units and Immobility", dated 1/10/14, which documented, "It is imperative that when a wandering resident declines in ability and had become immobile that (we) re-evaluate them being on a wandering unit. These residents no longer meet the criteria to remain in these units and it becomes a safety concern to be mixed in with wandering residents whom may come in their rooms and they cannot get away from them..." Review of the facility staffing revealed there was one licensed nurse and three CNAs scheduled for Station III on 1/7/14. Review of the daily assignment sheet did not reveal the unit census for 1/7/14. Review of the facility self-reports revealed 67 resident to resident altercations had occurred in the facility since January 2013. Resident #32 Resident #32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #32's chart revealed she had lived on Station I since her admission in 2006. The resident had a large doll house in her room on Station I. The resident enjoyed sitting in her room and looking at her doll house. Review of the interdisciplinary notes revealed on 12/12/13 at 4:00 PM, the resident was observed in "visible distress, shaking, trembling, stating "She's on my back"... Resident #32's roommate acknowledged she had been angry with Resident #32. Resident #32's room mate was moved to another room." On 12/14/13, Resident #32 was in the dining room and was verbally accosted by two other residents. The police were called. After this incident, the nurse documented the resident was ambulating with a walker and attempted to walk out of the facility three times. Resident #32 was transferred to Station II, a secured unit. The resident's guardian had to remove the doll house. Resident #32 has memory deficits and was not able to recall the incidents. On 1/30/14, during the initial tour of Station II, the nurse reported Resident #32 had recently been transferred to the unit after becoming "fearful" on Station I. The nurse reported Resident #32 seemed to have adjusted well to being on Station II. Resident #38 On 2/3/14 at approximately 8:15 AM, a call for help was heard coming from Resident #38's room. Observation revealed Resident #38 was lying on the floor beside her bed yelling for help. LPN-Employee #17 responded to Resident #38's yells for help, going into the room and talking to the resident. LPN-Employee #17 went to the dining room to ask a CNA for assistance. LPN-Employee #17 returned to Resident #38's room and tried to comfort the resident, but was unable to assist the resident back to bed without the assistance of another person. On 2/3/14 at approximately 8:23 AM, a CNA from Station I came to Station II to assist LPN-Employee #17 in getting Resident #38 back to bed. The resident was observed lying on the floor for at least eight minutes. On 2/3/14 at approximately 8:30 AM, LPN-Employee #17 was interviewed and reported the CNAs in the dining room were assisting residents with eating and were not able to help him get Resident #38 back to bed. Review of the staffing revealed there were two CNAs scheduled to work the day shift for Station II. Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review revealed Resident #1 was considered a high fall risk according to his last fall risk assessment and his care plan. The resident's physician ordered use of a soft helmet and a merry walker to help protect the resident from injury and prevent falls. On 2/3/14, Resident #1 was observed in the resident dining room eating breakfast. The resident's helmet was removed and he sat in a regular chair for his meal. The resident sat at a table in a corner of the room that was not easily observed by staff assisting other residents to eat. Resident #1 walked out of the dining room unobserved and unassisted on 2/3/14. The resident's gait was unsteady, but he walked to the nurses station without the protection of his helmet and use of the merry walker. Staff did not notice the resident left the dining room for approximately five minutes. Staff reapplied the residents helmet and placed him in a merry walker once they discovered he was walking without assistance and protection. The charge nurse on Station 3, confirmed Resident #1 was high risk for falls and should have been placed in his merry walker with the soft helmet before leaving the dining room. The nurse reported staff working on the unit were not familiar with the residents. Resident #23 Resident #23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. anxiety, neurogenic bladder, schizophrenia, and insomnia. Resident #23 had a prior history of aggressive behavior toward other residents and staff from admitted until August of 2013. The resident was on psychotropic medications and a sleeping sedative for insomnia until November 2013. A recommendation from the consulting pharmacist in November 2013, was to attempt a reduction in the psychotropic medication dosage. The attending physician agreed and reduced the Seroquel dosage for 3 days. After three days the physician discontinued the Seroquel and the Trazadone completely. There was no documentation the facility monitored Resident #23's behaviors after the reduction of the psychotropic medications or after the discontinuation of the medications. Evidence suggests that Resident #23 was involved in an aggressive altercation with Resident #24 on 1/7/14 resulting in injuries to Resident #24. A random observation conducted in the morning of 2/3/14, revealed the treatment cart was located in the hall without staff present. An examination of the treatment cart confirmed it was unlocked, enabling access to the various drawers of supplies. These supplies included dressings, ointments and wound cleansers as well as scissors and other equipment. This cart remained unlocked for approximately 10 minutes while the surveyor observed it. An interview with the treatment nurse upon her return to the treatment cart, confirmed the lock was broken and the cart could not be secured. Complaint #NV 048