Every finding on record at Nevada State Veterans Home - Boulder City

Based on observation, interview, record review and document review, the facility failed to ensure physician orders were followed for a resident's indwelling catheter, specifically, following the correct Foley size for 1 of 34 sampled residents (Resident 177). The deficient practice had the potential to place the resident at risk for catheter-related complications such as urethral trauma and pain.Findings include:Resident 177 (R177) was admitted on [DATE], with diagnoses including neuromuscular dysfunction of the bladder and chronic Foley catheter use.On 02/10/2026 in the morning, R177 was seated in wheelchair with a covered urinary bag hanging below center of the wheelchair. R177 indicated taking oral antibiotics for a suspected urinary tract infection and had experienced burning and pain to the catheter site the day before. R177 indicated not being certain if the night nurse replaced the catheter but the resident was relieved with the nurse's intervention. The admission minimum data set (MDS) dated [DATE], documented R177 was admitted with an indwelling catheter.The physician admission orders dated 01/30/2026, documented continued use of the indwelling catheter 16 French (size in diameter)/10 milliliters (ml) balloon (amount of sterile water or saline used to inflate the balloon which served as an internal anchor) for obstructive uropathy.R177's medication administration record (MAR) revealed the resident's Foley catheter was last changed on 01/31/2026 by the charge nurse.On 02/12/2026 at 7:59 AM, R177 permitted the surveyor to be present for assessment of Foley catheter by the Licensed Practical Nurse (LPN). The LPN removed R177's blanket and gown which revealed a red-colored balloon inflation port with black markings which read 18 Fr/30 cubic centimeters (cc). R177 stated not being able to remember whether the catheter was last replaced at the urology clinic or at the facility.On 02/12/2026 at 8:02 AM, the LPN reviewed R177's medical record and confirmed the resident's Foley catheter order was a 16 Fr/10 ml but the catheter observed was a size 18 Fr/30 cc. The LPN indicated the charge nurse signed off for the last Foley catheter change on 01/31/2026.On 02/12/2026 in the morning, the charge nurse reviewed R177's medical record and confirmed signing for the resident's Foley catheter change on 01/31/2026. The charge nurse explained the Foley catheter was changed by the nurse practitioner (NP) on 01/30/2026 because the nurses were having difficulty replacing the catheter, but the RN documented the catheter change in the MAR since the NP did not.A physician encounter dated 01/30/2026, documented nursing was having difficulty with changing foley catheter due to obstruction during insertion. This provider was notified and able to exchange foley catheter without complications. Patient tolerated exchange well. No hematuria or suprapubic pain.The medical record lacked documented evidence regarding what Foley size and balloon amount the NP used for the catheter change.On 02/12/2026 in the morning, the charge nurse stated nurses should not sign for other nurse's medication or treatment services. The charge nurse indicated not being able to explain why R177 had an 18 Fr/30 cc Foley which was not in accordance with physician orders nor did it align with the urology visit notes on 02/06/2026 where the urology staff supposedly changed R177's catheter with a 16 Fr Foley catheter.The urology visit note dated 02/06/2026, revealed a simple exchange was performed when a 16 Fr two-way Foley catheter was removed and a 16 Fr two-way Foley catheter was placed using standard sterile technique. The balloon was inflated with 10 cc of fluid. R177 tolerated procedure well.On 02/12/2026 at 11:18 AM, the charge nurse explained the nurses were expected to assess the Foley catheter site once every shift during the day, evening and night shift. The charge nurse indicated not being able to explain why the medical records did not align with the actual observation of R177's Foley catheter but stated any of the nurses assigned to R177 could have identified the discrepancy and reported this to the provider. The charge nurse indicated not being informed of R177's report of pain and burning at catheter site on 02/09/2026 by night shift when the resident recounted an intervention by a night nurse. On 02/12/2026 at 11:33 AM, the Unit Manager (UM) indicated being on duty when R177 was admitted on [DATE] and recalled the nurse having difficulty inserting a regular catheter, so the NP inserted a Coude (a special catheter featuring a curved or angled tip designed to navigate obstructions). The UM could not explain why R177 had an 18 Fr/30 cc Foley catheter and stated physician orders must align with actual observation.The facility policy Catheters/Indwelling Urinary - Use and Care of revised 12/16/2019, documented catheter insertions and removal required a physician order. Procedural guidelines were written in the most recent publication of Clinical Nursing Skills and Techniques adopted by the Director of Nursing Services.The Clinical Nurses Skills and Techniques (10th edition - March 12, 2021), documented to check the resident's plan of care for size and type of catheter. Use the smallest-size catheter possible - size 14 Fr to 16 Fr most common for adults and 12 Fr to 14 Fr for older adults. Document reason for catheterization, type and size of catheter inserted and amount of fluid used to inflate balloon. Resident complaints of burning and dysuria, hematuria, urgency and lower abdominal pain were to be reported as this may indicate a UTI.

Based on record review, observations, interviews, and document review, the facility failed to ensure:Prescribed parameters for blood pressure medications were consistently followed and the physician notified of low blood pressure readings for 1 of 34 sampled residents (Resident #2); and parameters for administering prescribed pain medication were followed for 1 of 34 sampled residents (Resident #134).These deficient practices had the potential to result in the inappropriate administration of blood pressure medication, leading to hypotension, dizziness, or falls, and the inappropriate administration of pain medication, which could have resulted in inadequate pain management.Findings include:Based on record review, observations, interviews, and document review, the facility failed to ensure: Prescribed parameters for blood pressure medications were consistently followed and the physician notified of low blood pressure readings for 1 of 34 sampled residents (Resident #2); and parameters for administering prescribed pain medication were followed for 1 of 34 sampled residents (Resident #134). These deficient practices had the potential to result in the inappropriate administration of blood pressure medication, leading to hypotension, dizziness, or falls, and the inappropriate administration of pain medication, which could have resulted in inadequate pain management. Findings include: Resident #2 (R2) was admitted on [DATE] with diagnoses including hypertension, diastolic congestive heart failure, hypertensive chronic kidney disease, ventricular fibrillation, chronic venous hypertension, and presence of a cardiac pacemaker. Record review showed physician orders for Carvedilol 3.125 milligrams (mg) one tablet by mouth twice daily for hypertension and heart failure, and Amiodarone HCl 200 mg one tablet by mouth once daily for ventricular fibrillation. Both orders included prescribed parameters to hold the medications if the systolic blood pressure was lower than 110 millimeters of mercury (mmHg), or a heart rate lower than 60 beats per minute. The medication administration record (MAR) for February 2026 documented parameters for holding the administration of medication were not followed, as shown below: 01/29/2026 at 7:30 AM Amiodarone 200 mg with B/P 104/65 02/04/2026 at 7:30 AM Amiodarone 200 mg with B/P 100/55 02/04/2026 at 7:30 AM Carvedilol 3.125 mg with B/P 100/55 02/06/2026 at 7:30 AM Amiodarone 200 mg with B/P 101/67 02/09/2026 at 6:00 PM Carvedilol 3.125 mg with B/P 98/52 On 02/13/2026 at 10:30 AM, a Licensed Practical Nurse (LPN) stated nurses were expected to verify residents' vital signs, including blood pressure and heart rate, prior to administering medications with holding parameters. The LPN indicated the failure to follow these parameters could result in adverse effects, such as hypotension. On 02/13/2026 at 2:30 PM, the Director of Nursing Services (DNS) confirmed both medications had been administered without following the prescribed holding parameters. The DNS stated nurses were expected to follow physician orders. The DNS indicated the nurses should have notified the attending physician for possible dose adjustment or discontinuation of the medication. The facility policy titled Medication- Administration and Treatment last revised on 11/21/2024, documented scheduled cardiovascular medications should have been held if blood pressure or pulse were outside of the established parameters prescribed by the healthcare practitioner. R134 was admitted on [DATE], with diagnoses including unspecified dementia with other behavioral disturbance and radiculopathy lumbar region and lesion of sciatic nerve. The admission minimum data set (MD) dated 09/29/2025, revealed R134 received scheduled and needed pain (prn) medications. A physician encounter note dated 09/22/2025, revealed R134 was admitted to facility with chronic lower back pain. A physician order dated 09/18/2025, documented to give Acetaminophen tablet 325 milligrams (mg), two tablets by mouth every four hours prn for mild pain. A physician order dated 02/08/2026, documented to give Hydrocodone-Acetaminophen oral tablet 5 mg-325 mg, one tablet by mouth every eight hours prn for pain rated 7-10 for 30 days. On 12/12/2026 at 8:01 AM, during a medication pass observation R134 reported a pain level of 5 out of 10 (5/10) to the lower back. A Licensed Practical Nurse (LPN) administered one tablet of Hydrocodone-Acetaminophen 5mg-325 milligrams. On 02/12/2026 at 8:17 AM, R134 indicated having lower back pain which was 4 to 5/10 on the pain scale. R134 reported receiving pain medications three times a day but did not know the name of the medications the nurses administered. On 02/12/2026 at 8:34 AM, the LPN reviewed R134's Medication Administration Record (MAR) and confirmed the Hydrocodone was not administered according to the physician order, as it was given for a pain rating of 5/10 when the order was for pain rated 7 to10. The LPN indicated there was no medication order covering pain rated 4 to 6/10 and a clarification order should have been obtained to cover the pain scale from 1to10. The facility's Pain Management policy revised 11/30/2024, documented assessments would have been done utilizing a zero (0) to 10 pain scale. Review of R134's MAR revealed Hydrocodone-Acetaminophen 5 mg–325 mg was administered below the ordered pain scale of 7 to 10/10 on the following dates: 01/12/2026: one administration at 6/10; one administration at 4/10 01/13/2026: one administration at 4/10 01/14/2026: one administration at 6/10 01/17/2026: two administrations at 6/10 01/19/2026: one administration at 6/10 01/20/2026: one administration at 4/10 01/21/2026: two administrations at 6/10 01/22/2026: one administration at 6/10 01/24/2026: one administration at 6/10 01/25/2026: two administrations at 6/10 01/26/2026: one administration at 6/10 01/27/2026: one administration at 4/10 01/29/2026: one administration at 6/10 02/01/2026: one administration at 6/10 02/03/2026: one administration at 6/10; one administration at 4/10 02/04/2026: one administration at 6/10 02/09/2026: two administrations at 6/10 02/12/2026: one administration at 5/10 (by direct observation) On 02/12/2026 at 10:37 AM, the charge nurse reviewed R134's medical record and indicated there was no pain medication order covering a pain rating of 4 to 6/10. The charge nurse indicated Tylenol was ordered for mild pain and Hydrocodone for pain rated 7 to10, and a clarification order should have been obtained. The charge nurse confirmed Hydrocodone was administered below ordered parameters on the above dates, which was not in accordance with physician orders. On 02/12/2026 at 12:30 PM, the Unit Manager (UM) confirmed physician orders were not followed when Hydrocodone was administered for a pain report of 5/10 during the medication pass earlier in the morning as well as on other dates documented on the MAR when Hydrocodone was administered below pain rating of 7 to 10. According to the UM, R134 did not have pain medication orders to cover a pain rating of 4 to 6 out of 10 and any nurse could have sought clarification orders from the physician. R134's pain management care plan initiated on 09/22/2025, documented to monitor and record pain severity, location and characteristics and administer pain medications per physician's orders. The facility's Medication Administration and Treatment policy revised 11/21/2024, documented the pain level would have been documented in the medical record with each dose of pain medication administered.

Based on interview, record review and document review, the facility failed to ensure an abnormal Hemoglobin A1C (HgbA1C) was communicated to and addressed by a physician for 1 of 34 sampled residents (Resident 23) and physician orders for quarterly HgbA1C blood test were carried out for 2 of 34 sampled residents (Resident 23 and 104). The deficient practice had the potential to place the residents at risk for diabetes-related complications and delayed treatment. Findings include:Resident 23 (R23) was admitted on [DATE], with diagnoses including unspecified dementia with other behavioral disturbance and diabetes mellitus. The admission minimum data set (MDS) dated [DATE], revealed R23 was admitted with an active diagnosis of diabetes mellitus and was not receiving Insulin. A physician order dated 04/30/2025, documented to complete an HgbA1C every three months by night shift on the last day of month. Review of medical record revealed R23's HgbA1C on 05/07/2025 was 7.0 percent (%). A lab interpretation note revealed the reference range for HgbA1C was 5.7 % or less while a value equal to or greater than 7.0 % reflected suboptimal blood glucose control for known diabetics.The medical record lacked documented evidence R23's HgbA1C of 7.0 % collected on 05/07/2025 was communicated to and addressed by the physician and subsequent HgbA1C were drawn on a quarterly basis in accordance with physician orders. On 02/12/2026 at 3:47 PM, the charge nurse explained it was the facility protocol to draw quarterly an HgbA1C for all residents with diabetes. The charge nurse reviewed R23's medical record and confirmed there was no documentation nursing staff communicated R23's high HgbA1C result to the physician and no documentation a provider addressed the abnormal finding. On 02/12/2026 at 3:55 PM, the charge nurse indicated R23 had behaviors of refusing care such as showers and laboratory draws but blood draws were performed on 07/21/2025, 09/17/2025, 11/19/2025, 12/26/2025 and 01/30/2026 but none of the tests included an HgbA1C which were missed opportunities to follow physician order for R23's quarterly HgbA1C draws. The charge nurse recounted R23 used to be on Metformin but the medication was discontinued on 07/18/2025 due to weight loss. On 02/12/2026 at 4:18 PM, the charge nurse indicated pharmacy may not have caught the missed lab draws due to the discontinuation of Metformin. The charge nurse verbalized if the high HgbA1C value was reported to the physician in May 2025 and quarterly draws were not missed; the provider could have considered restarting R23 on diabetes medications whether Insulin or non-Insulin. On 02/12/2026 at 4:24 PM, the unit manager (UM) indicated failure to report R23's high HgbA1c to the physician in May 2025 and missing ordered quarterly HgbA1C draws placed the resident at risk for hyperglycemia and poor blood glucose control. The facility's Laboratory Services policy revised 11/30/2024, documented laboratory services ordered for residents would have been processed and monitored and the attending physician would be notified of laboratory results which fall outside clinical reference ranges. Resident 104 (R104) was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with hyperglycemia. Physician admission orders dated 02/05/2025, documented to add HgbA1C (a blood test that shows the average level of blood glucose or blood sugar) if the resident was diabetic at admission and every three months. R104's medical record lacked documented evidence of HgbA1C testing results for the month of November 2025. On 02/13/2026 at 12:56 PM, A Registered Nurse (RN) verified the physician order required quarterly HgbA1C testing. The RN indicated R104 had HgbA1C tests completed on 02/06/2025, 05/08/2025, and 08/06/2025. There was no documentation of HgbA1C testing completed for November 2025. The RN confirmed the test should have been performed in November 2025. On 02/13/ 2026, at 1:49 PM, the Unit Manager confirmed the physician order for R104 HgbA1C testing was to be completed quarterly and acknowledged the test should have been completed in November 2025. The Unit Manager was unsure why the test was not completed in November 2005. On 02/13/ 2026 at 2:01 PM, the Health Information Coordinator was unable to locate R104's HgbA1C laboratory results for November 2025.

Based on observation, interview, record review, and document review, the facility failed to ensure the resident who had dementia was free from physical restraints for 1 of 6 sampled residents (Resident 6). This deficient practice had the potential to cause diminished physical functioning, increased confusion, psychosocial distress, and a decline in quality of life. Findings include: Resident 6 (R6) R6 was admitted on [DATE], with diagnoses including dementia, hearing loss, and major depressive disorder. The Admission Minimum Data Set, dated dated dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severely impaired cognitive status. R6 had routinely used a walker. The Nursing Progress Notes for the month of March documented multiple instances when R6 was confused, agitated, and restless. The Psychiatric Evaluation dated 03/25/2025, documented the encounter had been conducted in person. R6's safety had been assessed, and the current risk was deemed low; therefore, a safety plan was not required. The target behavior had been identified as sundowning. Residents with dementia had been noted to become more confused after sunset, which could involve agitation, pacing, wandering, exit-seeking, and other problematic behaviors. Psychotherapy had been encouraged, and medications had been prescribed. The Employee Statement signed dated 03/31/2025, documented Certified Nursing Assistant (CNA1) had been instructed to place R6 in another resident's Broda chair (a type of wheelchair which make it easier for caregivers to provide care with less stress on the resident and the caregiver) and secure the seat belt. CNA1 responded to the Charge Nurse (CN) had no knowledge of a physician's order to apply a seat belt. The Charge Nurse then stated in front of the staff, 'If you guys speak out, you guys will all be fired.' Due to fear of retaliation, CNA1 and Certified Nursing Assistant 2 (CNA2) complied with the instruction, placed R6 in the Broda chair, and secured the seat belt as directed. At approximately 10:30 PM, R6 remained at the nurse station until 1:30 AM and then was assisted back to the room upon appearing sleepy. A Physical Therapy Evaluation and Plan of Treatment dated 04/01/2025, documented a [AGE] year-old resident with a diagnosis of dementia. R6 was independent in bed mobility, transfers, and ambulation using a platform walker but required supervision to prevent falls. R6's gross motor coordination, sensation, and sensory processing were intact. The Interview Statement dated 04/04/2025, documented the Charge Nurse (CN) acknowledged R6 had been placed in the regular wheelchair and other times was in a Broda chair. The CN stated the chair had been reclined to reduce R6's pain and confirmed the positioning had a calming effect. The CN reported not considering the Broda chair a restraint because R6 could stand up and the chair was slightly reclined close to 90 degrees, but not more than 80 degrees, and denied the seatbelt had been fastened. The CN acknowledged R6 had verbally expressed, Odios mios, don't leave me, translated as Oh my God, don't leave me. The Interview Transcript dated 04/04/2025, documented CNA1 indicated R6 had been placed in a Broda chair, slightly reclined, and R6's feet were approximately 3 to 4 inches from touching the floor. CNA1 reported R6 requested to return to the room; however, the RN did not permit the transfer. Instead, the RN instructed CNA1 and CNA2 to transition R6 from the wheelchair and place in the Broda chair. CNA1 indicated R6 was sometimes anxious and agitated but was not considered at risk for falling. The Interview Transcript dated 04/04/2025, documented CNA 2 confirmed R6 had been at the nurse station a couple of times when R6 was agitated. CNA2 admitted having assisted in transferring R6 from the wheelchair to a Broda chair, but the seatbelt was not fastened. CNA2 confirmed the Broda chair was slightly reclined. On 05/01/2025 at 3:10 PM, R6 was observed in bed, coloring a book. R6 appeared pleasant and calm but exhibited confusion. During the conversation, R6 was verbally responsive. On 05/01/2025 at 3:20 PM, CNA2 indicated having witnessed R6 being placed multiple times in the Broda chair at the nurse station when agitated. CNA2 clarified the Broda chair had been tilted or reclined halfway back. CNA2 was uncertain about personally assisting with the transfer of R6 from the wheelchair to the Broda chair. CNA2 verbalized R6 was unable to independently adjust the Broda chair from its reclined position to its normal position, leaving R6 confined to the chair. CNA2 explained even if R6 wanted to get up from the Broda chair, it would have been difficult without sufficient strength. CNA2 indicated the Broda chair was typically used for transport, not for daily use or for behavioral management. CNA2 described a restraint as preventing a resident from moving freely or going where desired, thereby limiting the resident's mobility. CNA2 indicated the facility had provided education on abuse and restraint. On 05/01/2025 at 2:24 PM, the Director of Rehabilitation Services (DORS) explained R6 had been evaluated on 04/01/2025 and did not require rehabilitation services, as R6 had been independent and able to ambulate. The DORS explained the Broda chair was not typically used as a regular chair but rather for individuals requiring specialized positioning, such as those with Amyotrophic Lateral Sclerosis (ALS). The DORS explained although the Broda chair included tilt and recline functions, once tilted or reclined, it was unlikely a resident could exit independently due to the control mechanisms located at the back. The DORS explained use of a Broda chair required a physician order, clinical team evaluation, and frequent monitoring while in use, particularly for residents who tended to lean forward, which was unsafe. The DORS clarified the Broda chair could not be used to manage the resident's behavior or agitation by limiting mobility or solely for fall prevention. The DORS conveyed the use of a Broda chair for R6 was inappropriate and would constitute a restraint and a violation of resident rights if not properly authorized. On 05/01/2025 at 2:55 PM, the Nurse Practitioner (NP) indicated R6 had been agitated and restless, and the psychiatrist had evaluated R6, ordered medications and clinical interventions. The NP indicated the interdisciplinary team's recommendations required staff to alert providers. The NP had no recollection of ordering the Broda chair for R6 and stated it may have been ordered by another provider. On 05/01/2025 at 3:04 PM, the Minimum Data Set (MDS) Coordinator indicated R6 had been independent and able to get up. The MDS Coordinator explained the Broda chair was not recommended for R6 to treat medical symptoms, as the risks outweigh the benefits. The MDS Coordinator confirmed there had been no indication of Broda chair use for R6. On 05/01/2025 at 3:35 PM, another Charge Nurse (CN) indicated the use of a Broda chair required justification, a physician order, consent, a care plan, and monitoring. The CN explained the Broda chair was not intended to manage a resident's agitation or restlessness, nor to prevent falls, but was designated for residents with special needs. The CN acknowledged the Broda chair could be considered a restraint when an independent resident was contained in the reclined position, limiting mobility. R6's medical record lacked documented evidence a physician had been notified, or a physician order had been obtained for the use of the Broda chair. No justification, consent, or care plan had been completed. On 05/01/2025 at 3:50 PM, the Nurse Manager indicated the other staff involved or who witnessed the incident were unavailable for interview, remained employed at the facility, and worked night shifts or on other days. The Nurse Manager confirmed there was no order or justification in place for R6's use of the Broda chair and no documentation the concern had been discussed during the interdisciplinary team meeting. The Nurse Manager confirmed the medical record lacked documented evidence a physician's order had been obtained for the use of a Broda chair for R6. The Nurse Manager acknowledged limiting a resident's mobility was considered a restraint. On 05/01/2025 in the afternoon, the Administrator indicated the incident was investigated and the investigation process had been documented. The Administrator acknowledged the facility protocol had not been followed regarding the use of the Broda chair, and the involved staff was suspended, educated, and later reinstated. A facility policy titled Physical Devices, revised on 11/30/2024, indicated restraint-free care was supported through quality improvement, evidence-based practice, staff education, and informed decision-making. Physical restraints were defined as any device the resident could not remove easily that restricted movement. If a physical device was recommended, it required review and approval by the nurse manager or, in emergencies, the House Support Nurse. Documentation of need and completion of a physical device evaluation were required. A facility policy titled Abuse, Neglect, and Exploitation, revised on 03/15/2017, indicated residents had the right to be free from physical restraints not required to treat medical symptoms. The use of such restraints was considered abuse and strictly prohibited.

Based on observation, interview, record review, and document review, the facility failed to ensure: 1) A nutritional assessment was completed when significant weight loss was identified; 2) Interventions were implemented; and 3) A resident was reweighed when significant weight loss was identified, and weight was obtained monthly per policy for 1 of 30 sampled residents (Resident 139). The deficient practices had the potential to lead to further weight loss. Findings include: Resident 139 (R139) was admitted on [DATE], with diagnoses including chronic kidney disease (CKD), anemia, and malignant melanoma of the face. 1) R139's medical records lacked documented evidence nutritional assessments were completed when significant weight loss was identified. R139's Weight Summary documented as follows: -12/02/2024: 145.0 lbs. (Weight loss of 15 lbs.) -10/04/2024: 160.0 lbs. -09/04/2024: 161.0 lbs. -08/02/2024: 147.0 lbs. (Weight loss of 18 lbs.) -07/01/2024: 165.0 lbs. (Weight loss of 12 lbs.) -06/07/2024: 177.0 lbs. -06/03/2024: 170.0 lbs. -05/31/2024: 170.0 lbs. -05/24/2024: 169.0 lbs. -05/18/2024: 169.0 lbs. -05/17/2024: 168.0 lbs. -05/16/2024: 170.0 lbs. (Baseline weight upon admission) On 12/04/2024 at 2:58 PM, the Registered Dietitian (RD) started working at the facility on 10/07/2024, following a gap of approximately three months after the previous RD left. The RD indicated R139's height was 68 inches with a body mass index (BMI) of 22.0, indicating risk for weight fluctuations due to chronic heart failure, CKD, and a diuretic regimen. The RD confirmed the resident experienced a significant weight change from July to August. There was no nutritional assessment completed in August. The RD confirmed R139's BMI was 22, with a target goal of 25, and the weight loss was identified as unplanned and undesirable. The RD conveyed a nutritional assessment was vital for addressing significant weight changes and should have been completed to ensure interventions were implemented. On 12/05/2024 in the afternoon, the Director of Nursing (DON) confirmed the previous RD's last workday was 07/19/2024, and there was a gap when the new RD began working in October. The Food and Nutrition policy, revised 08/16/2024, documented resident assessments by an RD or RN within seven days of admission. RD assessments were required at least annually or with any significant status change. Significant weight changes prompted evaluation by the RD in collaboration with the resident, responsible party, nursing staff, and primary care physician. A Care Plan dated 05/17/2024 documented the Registered Dietitian (RD) was tasked with evaluating and recommending dietary changes as needed. Interventions included monitoring and reporting signs and symptoms of malnutrition to the physician, such as emaciation (cachexia), muscle wasting, and poor appetite. The goal aimed to maintain adequate nutritional status, evidenced by the absence of malnutrition signs and consumption of 50-75% of each meal daily through the review date. 2) R139's medical records lacked documented evidence interventions were implemented when significant weight loss was identified. On 12/05/2024 at 8:15 AM, the breakfast tray was untouched. R139 stated no appetite but expressed a desire to get well. On 12/05/2024 at 11:50 AM, a Licensed Practical Nurse (LPN) explained R139 had been admitted in May and was previously under hospice care, which was discontinued due to the need for eye surgery. Prior to this, R139 had a good appetite. The LPN indicated a notable decline in R139's condition had been observed, particularly from late October through November. A gradual decline in appetite and social engagement had been noted, with diminished participation in activities and meals. The LPN indicated R139 began withdrawing, becoming weaker, and showing visible signs of physical decline. On 12/05/2024 01:50 PM, R139's Power of Attorney (POA) indicated being unaware of R139's significant weight loss but had observed the decline. The POA mentioned was visiting the facility every two weeks and noted previously R139 had been going to the dining room to eat and had a good appetite. However, last month (November), the POA observed a poor appetite and less engagement. The POA indicated R139 had been discharged from hospice services before undergoing eye surgery and had expressed a desire not to return to hospice care. The Point of Care History documented 15 meal refusals between November 6 and December 4, 2024. From November 19 to December 5, 2024, R139's average meal intake ranged from 0-25%. On 12/04/2024 at 2:58 PM, the RD confirmed documenting the 06/04/2024 and 08/02/2024 weights as an error correction, despite not being employed at the facility when the weights were taken. The RD explained the significant weight loss was identified and documented as an error to resolve the trigger, but no interventions were implemented. The RD indicated R139 had previously been eating approximately 65% of meals. The RD explained a recent decrease in oral intake likely contributed to the weight loss, with current intake now at 0-25% of most meals, averaging around 20% over the past 14 days. Meal refusal occurred frequently. The RD explained R139's weight loss was unplanned and undesirable, and interventions such as appetite stimulants, oral nutritional supplements, laboratory assessments, or reweighs were not implemented. On 12/06/2024 at 12:46 PM, the attending physician was unaware of R139's significant weight loss after discharge from hospice and indicated potential interventions could have been implemented if notified earlier. 3) R139's medical records lacked documented evidence R139 was reweighed when significant weight loss was identified, and weight was obtained monthly per policy. R139's Weight Summary lacked documented evidence a weight was obtained in November 2024. The resident was not reweighed on 08/02/2024 after the weight obtained identified an 18-pound weight loss and on 07/01/2024 after the weight obtained identified a 12-pound weight loss. On 12/05/2024 12:30 PM, the Nurse Manager indicated the weight taken should not have been documented as an error correction, as it could have been interpreted as inaccurate. The Nurse Manager confirmed the process required reweighing residents for three consecutive days if weight changes were significant. The Nurse Manager confirmed no reweighs were completed in July and August, and R139's weight was missed in November. R139 was on isolation until November 4 and should have been reweighed after isolation. The Nurse Manager indicated reweighs were not conducted without direction from the RD, who issued weight alerts or email notifications for significant changes. The Charge Nurse was responsible for collaborating with the RD regarding weight concerns. The Charge Nurse explained monthly weights were taken by CNAs, with results encoded and monitored by the RD. The Nurse Manager was unaware of R139's weight loss and it was not discussed during the interdisciplinary team meeting (IDT). On 12/05/2024 at 1:28 PM, the Charge Nurse explained monthly weights were performed by day-shift CNAs for A beds and evening-shift CNAs for B beds. The Charge Nurse indicated weights were given to the unit secretary for encoding, the RD monitored residents' weights and advised nursing staff when reweighs were needed due to significant changes. Newly admitted residents were weighed weekly, then monthly, with reweighs directed as necessary. The Charge Nurse confirmed R139's November weight was not obtained, likely missed after isolation ended. On 12/05/2024 at 1:41 PM, the Unit Secretary explained residents' weights were obtained by CNAs on the first day of each month and handed to the Unit Secretary for encoding. Weight changes were highlighted in red, the Charge Nurse was notified, and the RD monitored residents' weights. The Unit Secretary indicated the weight forms were scanned into the electronic record after encoding. The Unit Secretary confirmed there was no weight encoded for R139 in November. On 12/04/2024 at 2:58 PM, the RD indicated the process required reweighing residents for three consecutive days to confirm significant weight changes but was unsure why this was not done. The RD indicated the weight discrepancy between R139's July and August weights were noted, and the resident should have been reweighed. No weight was taken in November due to COVID isolation, but this was not deemed valid given R139's significant weight loss. The RD expressed weight documentation was crucial for assessing nutritional status and preventing further decline. The facility policy titled Weight and Height Monitoring, revised 11/03/2024, documented weight recording upon admission and weekly for the first four weeks. Significant weight changes required reweighs for three consecutive days to determine an accurate weight, with the RD's notification to the IDT.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician / physician extender, and the resident representative were notified when a resident experienced poor appetite and a significant weight loss for 1 of 30 sampled residents (Resident 139). The deficient practice had the potential for the physician or family to not be aware of a change in a resident's condition which could result in a delay in a resident's plan of care. Findings include: Resident 139 (R139) was admitted on [DATE], with diagnoses including chronic kidney disease (CKD), anemia, and malignant melanoma of the face. R139's census documented received hospice services from 05/16/2024 to 06/11/2024. The Director of Nursing (DON) confirmed R139 was discharged from hospice services on 07/11/2024. A Physician Order dated 05/16/2024, documented a regular diet, regular texture, and thin consistency. 1) A Care Plan initiated on 05/17/2024 documented R139's diet was provided and served as ordered. The Registered Dietitian (RD) evaluated and made diet change recommendations as needed. Potential for nutritional problems related to end-stage diagnosis was identified. Interventions included monitoring and reporting signs and symptoms of malnutrition to the physician as needed, such as muscle wasting and poor appetite. The goal focused on maintaining adequate nutritional status, evidenced by the absence of malnutrition signs and symptoms and consuming 50-75% of every meal daily through the review date. A Nursing Progress Note dated 06/02/2024, documented R139's baseline as eating breakfast in the dining area with a good appetite and adequate fluid intake. Alert and able to communicate needs and wants. Self-fed without any issues. On 12/03/2024 at 12:59 PM, R139 was observed seated in a wheelchair, appearing weak and stuporous, and having dry, scaly skin. R139 did not respond to questions. On 12/05/2024 at 8:15 AM, the breakfast tray was untouched. R139 verbalized a lack of appetite but expressed a desire to get well. On 12/05/2024 at 11:50 AM, a Licensed Practical Nurse (LPN) explained R139 had been admitted in May and was previously under hospice care and discontinued due to the need for eye surgery. Prior to surgery, R139 demonstrated a good appetite. A notable decline in R139's condition was observed from late October through November. The LPN explained a gradual decrease in appetite and social engagement was noted, with diminished participation in activities and meals. The LPN further explained R139 began withdrawing, becoming weaker, and showing visible signs of physical decline. On 12/05/2024 at 1:50 PM, R139's Power of Attorney (POA) indicated not having been informed of R139's poor appetite but acknowledged observing the decline. The POA indicated visiting the facility every two weeks and previously observed R139 eating in the dining room with a good appetite. The POA indicated early November, a decrease in appetite and less engagement was observed. The POA mentioned R139 had been discharged from hospice services before undergoing eye surgery, and R139 expressed a desire not to return to hospice care. The Point of Care History documented 15 meal refusals between November 6 and December 4, 2024. From November 19 to December 5, 2024, R139's average meal intake ranged from 0-25%, falling short of the goal of 50-75% daily intake to maintain adequate nutritional status. On 12/04/2024 at 2:58 PM, the Registered Dietitian (RD) confirmed R139 had previously been eating approximately 65% of meals. The RD explained a recent decrease in the resident's oral intake likely contributed to the resident's weight loss. The resident's current intake was 0-25% for most meals, averaging around 20% over the past 14 days. The resident frequently refused meals. The RD confirmed there was a significant decline compared to R139's baseline. The RD confirmed a lack of documented evidence the attending physician or the POA were notified of R139's poor oral intake. On 12/05/2024 at 12:30 PM, the Registered Nurse (RN) Manager indicated the RD was responsible for collaborating with the physician regarding resident significant weight loss. The Nurse Manager explained monthly weights were taken by CNAs, with results encoded by the nurse manager and monitored by the RD. The Nurse Manager was unaware of R139's weight loss and verbalized it was not discussed during the interdisciplinary team meeting (IDT). The Nurse Manager confirmed no documentation existed indicating notification or collaboration with the resident, nursing staff, physician, and POA. 2) R139's Weight Summary documented the following: -12/2/2024: 145.0 lbs. (Weight loss of 15 lbs.) -10/04/2024: 160.0 lbs. -09/04/2024: 161.0 lbs. -08/02/2024: 147.0 lbs. (Weight loss of 18 lbs.) -07/01/2024: 165.0 lbs. (Weight loss of 12 lbs.) -06/07/2024: 177.0 lbs. -06/03/2024: 170.0 lbs. -05/31/2024: 170.0 lbs. -05/24/2024: 169.0 lbs. -05/18/2024: 169.0 lbs. -05/17/2024: 168.0 lbs. -05/16/2024: 170.0 lbs. (Baseline weight upon admission) On 12/04/2024 at 2:58 PM, the RD confirmed there were significant weight changes in July-August. R139's weight loss was unplanned and undesirable. The RD explained R139's weight was previously stable and at risk for weight fluctuations. R139 was previously eating 65% of meals, but recent decreases in oral intake were likely contributing to weight loss, and now eating 0-25% of most meals. The RD confirmed there was no documented evidence the physician or resident representative was notified of R139's weight loss On 12/05/2024 at 3:25 PM, the Director of Nursing (DON) indicated the staff were expected to notify the physician promptly of any changes in a resident's condition to ensure timely initiation of necessary interventions and document the notification in the progress notes. On 12/05/2024 at 12:30 PM, the Registered Nurse (RN) Manager indicated the RD was responsible for notifying the physician regarding the weight loss. The Nurse Manager confirmed there was no documentation the physician was notified regarding R139's significant weight loss The Nurse Manager indicated the physician should have been notified to obtain orders to promptly address the resident's change of condition. On 12/05/2024 at 1:28 PM, the Nurse Manager indicated the significant weight loss was a change of condition. The CRN indicated R139 had a decrease in appetite and the resident's family was informed of the weight loss in early December. On 12/05/2024 at 1:50 PM, R139's POA was unaware of the significant weight loss but acknowledged having observed a decline in R139's condition The POA confirmed no discussion had taken place regarding R139's weight loss until December 4, 2024. On 12/05/2024 in the afternoon, the Nurse Practitioner indicated staff were expected to notify the provider immediately regarding any changes in a resident's condition, including significant weight changes to address the issues promptly with an appetite stimulant, provide supplements, and order a blood workup. On 12/06/2024 at 12:46 PM, the attending physician was unaware of R139's significant weight loss after discharge from hospice. The physician emphasized staff were expected to promptly report changes in the resident's condition, particularly significant weight loss. The physician indicated an appetite stimulant, and supplements could have been initiated if informed. A facility policy titled Change of Condition, revised on 02/09/2024, documented nursing staff intervened promptly and thoroughly once an observed change in a resident's condition was identified. Significant change referred to a change in the resident's physical, mental, or psychosocial status, including deterioration in health, mental, or psychosocial status due to life-threatening conditions or clinical complications. A change of condition included any unusual signs or symptoms involving changes in physical or mental assessment. The charge nurse called the attending physician or physician extender and notified the family member or responsible party. The resident's condition was monitored, and documentation should have been completed.

Based on observation, interview, record review, and document review, the facility failed to follow the facility policy on referring residents for a Preadmission Screening and Resident Review (PASARR) Level 2 evaluation who acquired a new diagnosis indicative of a mental illness or begin a new psychotropic medication for 3 of 30 sampled residents (Resident 72, 139, and 98). The deficient practice had the potential to place residents at risk of not being evaluated for appropriate determination of necessary behavioral health services. Findings include: 1.) Resident 72 (R72) was admitted on [DATE] and readmitted [DATE], with diagnosis including type 2 diabetes mellitus with hyperglycemia, major depressive disorder, and senile degeneration of brain. On 12/03/2024 at 9:11 AM, R72 was observed in the dining room sitting on wheelchair with eyes closed and calm. R72 did not display concerning behaviors or symptoms of distress. A Nevada PASARR Level I Identification Determination dated 08/02/2021, revealed R72 did not have dementia, mental illness (MI), mental retardation (MR), or any related condition (RC), and was deemed appropriate for nursing facility placement. R72's Admission Record Diagnosis Information documented new diagnosis of anxiety disorder with onset date of 10/26/2023, major depressive disorder with onset date of 12/15/2023, and post-traumatic stress disorder with onset date of 04/16/2024. R72's medical record lacked documented evidence a referral was made for PASARR Level 2 evaluation after the resident was diagnosed with anxiety disorder, major depressive disorder, and post-traumatic stress disorder. On 12/06/2024 at 10:05 AM, a Licensed Social Worker (LSW 1), explained was not familiar with the PASARR Level 2 evaluation process. LSW 1 reported not knowing if R72 was referred for PASARR Level 2 evaluation. On 12/06/2024 at 11:05 AM, a Licensed Social Worker (LSW 2), was unaware of the policy for PASARR a Level 2 evaluation. LSW 2 acknowledged not knowing social services involvement and responsibilities in the process to request a PASARR Level 2 evaluation after a resident had a new diagnosis of mental illness. On 12/06/2024 at 11:53 AM, the Social Services Supervisor confirmed R72's medical record lacked documented evidence a referral for a PASARR Level 2 evaluation was completed. The Social Services Supervisor acknowledged a referral for evaluation should have been completed after the diagnoses were identified. 40131 2.) Resident 139 (R139) was admitted on [DATE], with diagnoses including chronic kidney disease, heart disease and post-traumatic disease syndrome (PTSD). The medical record lacked documented evidence R139 was referred for a new level of care assessment (LOC) and/or a PASARR Level 2 referral after new psychiatric diagnoses was identified since R139 last comprehensive assessment. On 12/06/24 at 1:00 PM, the Social Services Supervisor confirmed there was no documented evidence R139 was referred for a new level of care assessment (LOC) and/or a PASARR Level 2 referral after a new psychiatric diagnosis was identified. 40142 3.) Resident 98 (R98) was admitted on [DATE], with diagnoses including Parkinson's disease, major depressive disorder and post-traumatic stress disorder (PTSD). A pre-admission screening and resident review (PASARR) Level 1 dated 01/19/2023, documented R98 did not have any mental illness, mental retardation, intellectual disability or dementia (negative PASARR). R98 was determined to be appropriate for nursing facility placement but may require a level of care (LOC) assessment. The Admission Minimum Data Set (MDS) dated [DATE], revealed R98 did not have any psychiatric mood disorders and was not on any psychoactive medications. A Psychiatric Note dated 05/08/2023, documented R98 had PTSD and would have flashbacks from being a paratrooper, unspecified schizophrenia, delusional disorder and major depression. Start Sertraline (an anti-depressant). The Annual MDS dated [DATE], revealed R98 had a diagnosis of depression, PTSD and psychotic disorder and was receiving psychoactive medication specifically an anti-depressant. The medical record lacked documented evidence R98 was referred for a new level of care assessment (LOC) and/or a PASARR Level 2 referral after new psychiatric diagnoses was identified since R98's last comprehensive assessment. On 12/06/2024 at 10:53 AM, the Administrator confirmed residents admitted with a negative PASSAR and was diagnosed with new psychiatric illness met the criteria for a referral for a PASARR Level 2 evaluation. The Administrator deferred to social services for the facility's PASARR process. On 12/06/24 at 11:13 AM, Licensed Social Worker (LSW 1) indicated being employed for [AGE] years and explained social services was not involved in the PASARR referral process. LSW 1 verbalized not being well-versed on the PASARR process and explained the former medical records director who left the facility early this year oversaw all PASARR referrals. LSW 1 reviewed the facility's PASARR policy and indicated not being aware of the responsibilities the social services had with PASARR referrals. On 12/06/24 at 11:53 AM, the Social Services Supervisor indicated the PASARR process was new to social services because the former medical records director used to be solely responsible for identifying and referring residents for LOC assessments and/or PASSAR Level 2 evaluation. The social services supervisor indicated PASARR was delegated to social services around March or April 2024, but no clear process had been developed with regards to identifying and referring residents for PASARR Level 2. The social services supervisor indicated not being well-versed with the PASARR referral process and confirmed there had been no residents referred for a new LOC assessment or PASARR Level 2 evaluation ever since the former medical records director left in early 2024. On/12/06/2024 at 1:19 PM, the Administrator confirmed the social services supervisor's account where no residents have been referred for new LOC or PASSAR Level 2 evaluation since the former medical records director left in March-April 2024. The Administrator indicated starting employment in the middle of May 2024 verbalized being inclined to believe the social services department received no training on PASARR and confirmed the facility currently had no clear process on how to identify residents who meet the criteria for an LOC/PASARR Level 2 referral. The PASRR and Level of Care Screening policy revised 02/22/2028, revealed a PASARR was required to be completed prior to admission on all residents. If there has been a change of condition since the last PASARR prospective resident would be referred of LOC assessment. PASARR screening shall be requested by the unit social worker on residents who acquire a new diagnoses indicative of mental illness or beginning on a new psychotropic medication. Social services would forward the PASARR requests to medical records department. Medical records personnel would be responsible for faxing the PASARR requests to the screening entity and tracking their status.

Based on observations, interviews, record review, and document review, the facility failed to ensure a care plan was revised to include current communication practices for 1 of 30 sampled residents (Resident 69). The deficient practice placed the resident at risk for inaccurate communication leading to inappropriate care. Findings include: Resident 69 (R69) was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, dysarthria following unspecified cerebrovascular Disease, major depressive disorder, dysphagia, and dysphonia. On 12/03/2024 in the morning, the resident was lying in bed with a Dynavox box (a type of communication device) in the room, but it did not appear R69 was using it. R69 was only able to answer yes/no questions. On 12/04/2024 at 9:18 AM the Speech-Language Pathologist (SLP) explained R69 had a hard time vocalizing and articulating. The resident's voice was inconsistent and dysarthric (a motor speech disorder in which the muscle used for speech are weak). The SLP stated R69 had a history of stroke and currently had head and eye tremors. The SLP indicated the resident may not be utilizing the Dynavox for communication due to the Dynavox utilized eye gaze technology. It was not easy for R69 to use due to the eye tremors. The SLP explained R69 did use alternate communication methods to get needs and wants known. R69 used communication spelling boards, finger spelling via sign language, and was very accurate with responding to yes/no questions. A care plan for communication had documented R69 had difficulty with communicating their needs. The care plan provided an intervention of using the computer (Dynavox) for communication as it provided R69 with a feeling R69 had some control left. The care plan had not been revised with the new communication intervention methods of the alphabet communication board, finger spelling via sign language, and yes/no questioning. On 12/04/2024 in the morning, the Registered Nurse (RN) Charge Nurse explained the care plan was a resident centered outline which informed all the caregivers how to best care for the individual resident including their preferences, needs, and equipment to be used. Without a correct care plan, it could lead to incorrect care being given. On 12/04/2024 at 10:36 AM the RN Unit Manager stated R69 communicated using: an alphabet communication board where R69 spelled out words, yes/no responses to staff yes/no questions, a computer to assist with communication (Dynavox), and R69 could use sign language for the alphabet to spell out words to communicate. The RN Unit Manager acknowledged the only communication intervention method care planned was the computer (Dynavox). The RN Unit Manager confirmed the other communication intervention methods should have been in the care plan for R69. A facility policy titled Care Planning revised 04/24/2019 documented the care plan will be updated as changes in resident status occur, but not less than every 92 days. The policy documented the care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interview, record review, and document review, the facility failed to ensure an omitted dose due to drug unavailability was prevented for 1 of 30 sampled residents (Resident 255). These deficient practices could have the potential to result in adverse health outcomes including delayed healing or ineffective treatment. Findings include: 41903 Resident 255 (R255) was admitted on [DATE], with diagnosis including urinary tract infection, polyneuropathy, and chronic pain syndrome. On 12/04/2024 at 8:30 AM, R255 was observed in their room while interacted with a nurse and discussed medications refused and medications to be administered. R255 was alert and oriented and no observation concerns were identified. A Physician Order dated 11/11/2024 documented Zinc Oxide Ointment 10%, apply topically two times a day for excoriation, topical. The morning dose was to be administered at 8:00 AM. On 12/04/2024 at 8:35 AM, the nurse failed to administer Zinc Oxide Ointment 10% as ordered by the physician. The nurse explained the electronic system showed the medication should have been available in the medication cart, however, was unable to locate the Zinc Oxide 10% medication tube in the medication cart. The nurse confirmed the medication was not administered as ordered. On 12/04/2024 at 2:09 PM, a Nurse Manager confirmed Zinc Oxide 10% ointment should have been available in the medication cart for administration by the nurse as scheduled. The Nurse Manager explained a wound care nurse confirmed the medication should have been available in the nurse's medication cart and administered to R255 as ordered. A facility policy titled Medication Administration and Treatment dated 04/12/2002, documented medications shall be administered within one hour before and one hour after scheduled times unless timing is of critical nature.

Based on observation, interview, record review and document review, the facility failed to identify a new skin impairment for 1 of 30 sampled residents (Resident 26). The deficient practice placed the resident at risk for worsening skin impairments and diminished quality of life. Findings include: Resident 26 (R26) admitted to the facility on [DATE] with diagnoses including stage 4 pressure ulcer upon admission. On 12/04/24 at 9:46 AM, R26 stated having a pressure ulcer acquired from another facility but developed one while in the current facility. R26 believed the new pressure ulcer developed because of lying in bed all day and sometimes in excrement for long periods of time. Review of R26's care plan revised on 10/09/2024 identified the following: R26 was at risk for skin breakdown, skin tears, bruising/skin discoloration and pressure ulcers related to impairment of physical mobility post total left hip surgery, refusal to be turned and repositioned, and fragile/sensitive skin. Goals included: Resident will not develop pressure ulcers through the next review date; the resident will have intact skin free of blisters, redness, discoloration; administer treatments as ordered and monitor for effectiveness. Interventions included: monitor/document/report as needed any changes in skin status; appearance, color, wound healing, signs/symptoms of infection, wound size (length x width x depth), stage; and provide skin care each shift and as needed. On 12/05/2024 at 11:22 AM, the Minimum Data Set (MDS) Nurse stated R26 was admitted with a stage 4 pressure that healed in May 2024. The MDS Nurse stated R26 resident did not have any other pressure ulcers or wounds at this time. On 12/05/2024 at 12:12 PM, the Wound Care Nurse (WCN) stated new resident skin issues were reported to them by the Certified Nursing Assistant (CNA). The nurse indicated R26 had a healed stage 4 pressure ulcer wound and did not have any other wounds. On 12/05/2024 at 12:57 PM, R26's CNA turned R26's body to the left side that revealed 2 dressings located on mid to outer right buttock. The CNA peeled back the two dressings that revealed the outer dressing, with a reddened area with broken skin. On 12/05/2024 at 1:01 PM, the Charge Nurse on the unit stated the R26 was not on any wound management based on a list of all residents on wound care and was not receiving any wound care. On 12/05/2024 at 12:24 PM, the Unit Charge Nurse, WCN and R26's CNA looked at the resident's buttock where the open wound was located. The WCN indicated the dressings were placed days ago for protection and confirmed the skin was not open. The WCN was not aware the resident's skin was open as no one had reported it. The WCN stated the open skin wound appeared to be a moisture associated skin damage (MASD) and had a high likely hood of developing into a pressure ulcer. On 12/05/2024 at 2:43 PM, the Director of Nursing (DON) stated the CNA would report any new skin issues to the nurse who would then contact the WCN. DON stated the WCN was not aware of the wound because no one reported it. Review of a facility policy titled Pressure ulcer prevention and care dated 10/16/2016, documented the following: 1. All residents were to have a daily head to toe skin check 2. Check resident more frequently if incontinent 3. CNA's and Licensed Practical Nurses (LPN) will notify the charge nurse of any abnormal skin findings.

Based on interview, record review, and document review, the facility failed to ensure a pharmacy recommendation for a gradual dose reduction (GDR) was communicated to the physician for 1 of 30 sampled residents (Resident 45). The deficient practice had the potential to cause the resident to be administered a higher dose of medication than was necessary. Findings include: Resident 45 (R45) was admitted on [DATE], with diagnosis including Alzheimer's disease with late onset, dementia, and major depressive disorder. On 12/05/2024 at 7:15 AM, the resident was observed lying in bed, eyes closed, no signs and symptoms of pain or distress. A Physician Order dated 07/24/2024, documented Escitalopram Oxalate Oral Tablet 20 milligrams (mg) 1 tablet by mouth in the morning for depression/anxiety. A Psychoactive Medication Consent dated 07/25/2024, documented Escitalopram 20 mg 1 tablet by mouth in the morning, specific target behaviors depression/anxiety. Potential side effects included headache, constipation, and decreased appetite. A Care Plan dated 04/02/2024 documented R45 was at risk for side effects related to the use of antidepressants, including Escitalopram for depression. A Medication Regimen Review dated 09/01/2024 - 09/23/2024 listed a group of residents, including R45, who received recommendations made by the pharmacy regarding their medication regimen. R45's medical record lacked documented evidence of the recommendations made by the pharmacy between 09/01/2024 - 09/23/2024. On 12/06/2024 at 1:18 PM, the Health Information Coordinator, reported the medical record lacked the pharmacy medication regimen recommendation for R45, for 09/01/2024 - 09/23/2024. The Health Information Coordinator obtained a copy of the recommendations directly from the pharmacy consultant. The Health Information Coordinator acknowledged the section of the form for the physician was blank, was not marked reviewed or signed by the physician. The Health Information Coordinator explained the medical record lacked documented evidence the physician reviewed the recommendations. Note to Attending Physician/Prescriber dated 09/19/2024, addressed to the physician, documented a dose decrease to Escitalopram 10 mg daily was to be considered due to R45's advanced age. The physician/prescriber response and signature section of the form was blank. On 12/06/2024 at 1:36 PM, the Administrator explained when recommendations were received from the pharmacy, they were placed in a binder for the physician to review and sign. The Administrator acknowledged the recommendation form for R45 was not found in the binder. The Administrator acknowledged the recommendation was not reviewed by the physician. On 12/06/2024 at 1:55 PM, a Nurse Manager acknowledged there was no documentation confirming the recommendation made by the pharmacy was provided to the physician for review. A facility policy titled Medication Regimen Review dated 07/2/12017, documented the consultant pharmacy performed a comprehensive review of each resident's medication regimen. Findings and recommendations were reported to the director of nursing and the attending physician. Copies of the medication regimen should have been on file as part of the resident's permanent medical record.

Based on interview and document review, the facility failed to ensure 1) the arbitration agreement stated neither the resident or their representative is required to sign the agreement as a condition of admission or to receive care at the facility, and 2) the arbitration agreement explicitly grant the resident or their representative the right to rescind the agreement within 30 calendar days of signing it. The deficient practice had the potential to deny admitted residents or their representatives the right to withdraw from the agreement within the 30-day after the signature as well as to deny the resident or representative their right to resolve their dispute in the court of law. Findings include: A facility document titled .Home Admission Contract, documented by signing, a resident confirmed to have received a copy of the document, and the provisions of the contract had been explained in a clear and understandable manner. The document indicated all the questions formulated by the resident had been answered. Section 10 of this contract was Arbitration. This section of the document revealed by signing this contract, the resident or resident representative agreed to have any dispute between the resident and the facility decided by arbitration, and the resident was giving up their right to a jury or court trial. The arbitration section contained lacked documented evidence the resident or resident representative were required to sign the arbitration section as a condition of admission or as a requirement to continue receiving care at the facility. The arbitration section lacked documented evidence the resident or resident representative could revoke the agreement by providing written notice to the facility within 30 calendar days of signature. There was no separate signature available for this section of the contract. Section 4 of this contract was Consent to Services. This section of the document revealed by signing this contract, the resident or their representative consents to the facility providing skilled nursing care as directed by said attending physician. On 12/06/2024 at 12:34 PM the administrative assistant in admissions explained the admissions agreement was sent out to the perspective resident/resident representative via email three to four days in advance of the potential resident being admitted to the facility. If there were any questions or issues with the admission agreement, the potential resident/resident's representative would call, email, or ask us on the day of admission to discuss any of their questions/issues. The administrative assistant in admissions stated there have been no issues where the resident or resident's representative did not want to sign the agreement because of the arbitration clause. But the agreement must be signed because it included the consent for the facility to treat the potential resident. On 12/06/2024 at 2:02 PM, the compliance officer acknowledged the arbitration section of the admissions contract did not say the potential resident or resident representative were not required to sign this section of the admissions contract. The compliance officer acknowledged the arbitration section of the admissions contract did not explicitly grant the resident or resident representative the right to rescind the arbitration agreement within 30 days of signing it. The compliance officer did reiterate that signing the arbitration agreement was not a condition of admission or to receive care at the facility. On 12/06/2024 in the afternoon, the administrative assistant in admissions acknowledged all current residents had a signed contract on file. On 12/06/2024 in the afternoon, the compliance officer stated the facility had no policy regarding arbitration.

Based on interview and document review, the facility failed to ensure the Arbitration Agreement provided for the selection of a neutral arbitrator agreed upon by both parties; and for the selection of a venue that was convenient to both parties. The deficient practice had the potential to obstruct a resident's ability to make a well-informed decision about signing the arbitration agreement. Findings include: A facility document titled .Home Admission Contract, documented by signing, a resident confirmed to have received a copy of the document, and the provisions of the contract had been explained in a clear and understandable manner. The document indicated all the questions formulated by the resident had been answered. Section 10 of this contract is Arbitration. This section of the document revealed by signing this contract, the resident or their representative agreed to have any dispute between the resident and the facility decided by arbitration administered by the National Health Lawyers Association and not a neutral arbitrator agreed upon by both parties. The arbitration section did not provide for the selection of a venue that was convenient to both parties. On 12/06/2024 at 2:02 PM the compliance officer acknowledged the arbitration section of the admissions contract did not provide for the selection of a neutral arbitrator agreed upon by both parties, but instead had to use the National Health Lawyers Association to arbitrate disputes. The compliance officer acknowledged the arbitration section of the admissions contract did not provide for the selection of a venue that was convenient to both parties. The Compliance Officer stated the facility did not have a policy for arbitration.

Based on observation, record review, document review, and interview, the facility failed to ensure a nurse performed hand hygiene after medication administration of an intradermal patch, after removing gloves and prior to administration of another resident's medication for 1 unsampled resident (Resident 113). The deficient practice had the potential for cross-contamination and the spread of infection. Finding Include: Resident 113 (R113) was admitted on [DATE] with diagnosis including Parkingson's disease without dyskinesia, Alzheimer's disease, and dementia. A Physician Order dated 09/19/2024 documented Exelon Patch 4.6 milligrams (mg), 1 patch every day transdermal. Indication diagnosis was dementia with behaviors. On 12/04/2024 at 7:44 AM, R113 was observed in the dining area. A nurse removed the existing Exelon Transdermal Patch and replaced it with a new patch. The nurse failed to perform hand hygiene after removing gloves and prior to administration of medication to another resident. On 12/04/2024 at 8:00 AM, the nurse acknowledged not performing hand hygiene after administering medication to R113. The nurse confirmed hand hygiene should have been completed after medication administration and removal of gloves, to prevent cross-contamination and prevent the spread of infection. On 12/04/2024 at 1:54 PM, a Charge Nurse, acknowledged hand hygiene should be performed after removal of gloves and prior to the start of care for another resident. A facility policy titled Infection Prevention and Control Policy and Procedure Hand Hygiene dated 11/17/2010, documented all healthcare workers shall practice effective hand hygiene when providing care to residents. When to utilize effective hand hygiene included before and after resident contact (even if gloves were worn), and handling medication. Hand hygiene was to be performed before putting on gloves and after removal of gloves.

Based on observations, interviews, and document review the facility failed to ensure residents received warm and palatable meals. The deficient practice placed the residents at risk for not consuming meals to maintain appropriate nutrition needed for overall good health. Findings include: On 01/23/2024 at 8:24 AM, the dishwasher temperature was below acceptable levels with current reading of 101 degrees Fahrenheit. Temperature log was completed for dishwasher and did not reveal any previous concerns. The Dietary Manager indicated dishwasher temperature was new concern, however the service company was scheduled to be at the facility in the next several hours and would inform the service company of identified concern. On 01/23/2024 at 8:45 AM, the Dietary Manager indicated the dishwasher would be taken out of service until further notice and meals would primarily be served in styrofoam containers until dishes could be properly cleaned and sanitized. On 01/23/2024 at 9:23 AM, Resident 24 (R24) indicated food was cold for all meals and hot plates do not work. On 01/23/2024 at 12:16 PM, Resident 88 (R88) verbalized R88 did not eat lunch because the preparation of food was not acceptable due to being in styrofoam container. R88 expressed there was not enough staff in kitchen. On 01/23/2024 at 12:02 PM, R24 indicated the facility serves food in styrofoam container all the time and was the main reason food was always cold. R24 verbalized the dishwasher was broken and not enough staff in kitchen. On 01/23/2024 at 12:42 PM, Resident 69 (R69) explained food was normally served on plates when in the main dining area. R69 indicated food was colder when served in the smaller unit dining rooms and resident rooms due to use of styrofoam containers. The tray line temperature log completed by the facility documented temperatures for hot and cold food were being monitored prior to placing on plate to be delivered to residents and were within acceptable ranges. On 01/24/2024, a meal cart left the kitchen at 8:08 AM and was delivered to sidewinder unit at 8:10 AM. There were six residents in the dining area and the rest were in separate common areas or in room for delivery of tray. Staff began delivering meal trays at 8:15 AM starting with the dining area, moving cart to resident unit areas at 8:30 AM. On 01/24/2024 at 8:20 AM, the Charge Nurse indicated a meal tray had been removed from cart and was sitting on table for extended period and meal was in a styrofoam container. The Charge Nurse verbalized was important to deliver the meals before getting cold. On 01/25/2024 at 8:27 AM, a breakfast test tray was obtained and temperatures were measured with the Dietary Manager. The test tray consisted of blueberry pancakes, oatmeal, and scrambled eggs. All temperatures were tested using facility thermometer and confirmed by the Dietary Manager as follows: Blueberry pancakes, 115 degrees Fahrenheit. Oatmeal, 120 degrees Fahrenheit. Scrambled eggs, 115 degrees Fahrenheit. The plate used for food serving was resting on a metal plate warmer, the plate warmer had very little residual heat. The surveyor findings of the temperature and palatability of food tested revealed the taste and texture were acceptable, however the temperature was not optimal. The Dietary Manager also tested the food items and verbalized the hot breakfast foods did not meet palatable temperature as normally expected of hot foods. On 01/25/2024 at 11:33 AM, the Charge Nurse indicated several residents have complained when receiving meals in styrofoam indicating meals were not hot. The charge nurse indicated there was a problem with the dishwasher on 01/23/2024 and most meals were served in Styrofoam container for lunch. The charge nurse explained the staff apologized to the residents and indicated the dishwasher was fixed by the end of lunch. The charge nurse verbalized it was explained to the residents and the residents were told the food could be reheated if needed. On 01/25/2024 at 1:10 PM, the Dietary Manager verbalized a dishwasher quit on first day of survey and two cooks left in past 2-3 weeks due to facility vaccine requirements. The Dietary Manager indicated the service provider had the dishwasher shut down from middle of breakfast to end of lunch on 01/23/2024 which caused use of styrofoam. On 01/26/2024 at 7:41 AM, the meal cart was delivered to the sidewinder unit with two residents currently in the dining area. On 01/26/2024 at 8:00 AM, a Certified Nursing Assistant (CNA) indicated the CNAs were initially responsible for delivering meal trays to residents. Some of the CNAs were still assisting other residents with activities of daily living and were late to assist with meal delivery today. On 01/26/2024 at 8:04 AM, there were two staff members taking trays out of cart to deliver to residents in the dining area. Cart was moved to resident unit area approximately one minute later. On 01/26/2024 at 8:19 AM a Styrofoam test tray was obtained and surveyor tested with the Dietary Manager. On the test tray were two slices of French toast and one container of cream of wheat. The french toast was tested and temperature was confirmed by the Dietary Manager to be 90 degrees Fahrenheit. The cream of wheat was tested and found to be at 110 degrees Fahrenheit, confirmed by the Dietary Manager. On 01/26/2024 at 8:28 AM, the Dietary Manager indicated the process of getting meals delivered to residents could be improved for timeliness however different departments were dealing with some of the same concerns with not having enough staff to coordinate resources appropriately. The Dietary Manager indicated the temperature for the main meal was not appropriate to serve residents and would most likely need to be reheated or replaced. The Dietary Manager verbalized an email was sent to unit charge nurse when cart was leaving the kitchen to be delivered on unit. On 01/26/2024 at 8:35 AM, a charge nurse indicated if the staff verbalized needing additional help the nurses and charge nurse would also assist with meal delivery and should be delivered in a timely manner with priority to residents in the dining area and alternate delivery systems such as residents in isolation using styrofoam. On 01/26/2024 at 8:46 AM the Dietary Manager indicated there have been complaints for extended period of time from residents regarding the temperature of food especially when delivered in styrofoam containers. The Dietary Manager verbalized there have been discussions regarding concerns from residents over temperature level of food but no further follow up had been completed. A facility document titled Meal Times indicated the following times for breakfast meal service: 7:30 AM for the main dining area 7:00 AM for residents in the Cove unit 7:10 AM for residents in the Mariner unit 7:30 AM for residents in the [NAME] unit 7:40 AM for residents in the Sidewinder unit The resident council minutes from December 2023 and January 2024 documented resident complaints regarding cold food. A facility policy titled Food and Nutrition Services (revised 06/14/2017) documented food and drink items were prepared to meet individual needs by methods which were flavorful and attractive in appearance and served at a safe and appetizing temperature.

Based on interview and document review, the facility failed to ensure 1 of 31 sampled residents (R155) were free from mental / verbal abuse. The deficient practice resulted in potential psychosocial harm for the resident. Findings include: A review of the Abuse Neglect and Exploitation policy revised 03/15/2017, documented verbal abuse was described as oral, written, or gestured language toward a resident that was derogatory or disparaging. This was without regard to the resident's ability to see, hear, or comprehend such language. Mental abuse included but was not limited to statements or actions that humiliate, harass, and threats of punishment of deprivation. A review of the Civility Pledge posted throughout the facility documented staff will: - Hold themselves responsible for their words, thoughts, and actions - Speak in a civil manner to others, even if they do not agree with what is being communicated - Respectfully point out uncivil behavior from others. - Genuinely attempt to listen to and understand points being made by others. - Create a safe space for questioning, debate, and authentic dialogue - Communicate in a manner that is open, positive, and does not judge, blame, or shame. - Address conflict early, appropriately, and in private, respecting and acknowledging the appropriate channels for responding to conflict. Verbal Abuse Resident 155 (R155) R155 was admitted on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS), post-traumatic stress disorder, and motor neuron disease. A Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. On 01/23/2024 at 1:38 PM, R155 verbalized there was an altercation between the resident and the facility Administrator on 01/09/2024. The Administrator and two maintenance personnel removed pictures from the wall and furniture, including a recliner, from the common area outside R155's room. R155 advised had told the Administrator would be better to talk to the residents and ask them how they feel about the furnishing. R155 indicated the Administrator did not respond and walked away. The resident verbalized the Administrator returned with the Abuse Coordinator and continued to remove furniture. R155 continued to voice concerns and Administrator had replied, if you don't like it here you should leave. On 01/23/2024 at 1:42 PM, R155 expressed the Administrator's behavior was rude and disrespectful. On 01/25/2024 at 11:22 AM, the Abuse Coordinator reported during rounds the facility removed puzzles and furniture from the facility. Ten minutes into rounding R155 began yelling the Administrator did not care about the resident. R155 began crying telling staff they were dying and had ALS. The Administrator had responded by saying Sir, you have come here for care, but if you are unhappy, there are other places you can go to get care. The Abuse Coordinator felt it was not the best thing to say; however, did not consider the remark abusive. The Abuse Coordinator confirmed the resident was very upset by the Administrator's comment. On 01/25/2024 at 11:33 AM, a Registered Nurse (RN) reported on 01/09/2024, R155 was observed talking to the Administrator regarding furniture being removed without consulting the residents. The RN was not close enough to hear the exact conversation, however; heard tension in the tone of voice in both R155 and the Administrator. Following the incident, the RN spoke with R155 and the resident's family member. Based on how R155 and the family member described the incident, the RN would consider the situation to be verbally abusive. The RN later heard the Administrator comment, must have triggered R155. The RN indicated a responsibility to report abuse to the Abuse Coordinator. The RN explained had not reported the incident because the Abuse Coordinator was present, and the RN was informed the facility was taking care of the incident. On 01/25/2024 at 12:40 PM, the Licensed Social Worker indicated an interview was conducted with R155 on 01/22/2024. R155 divulged to the Social Worker the Administrator told the resident if they were not happy here, they can leave. R155 was not happy about the Administrators statement because the resident felt they earned the right to be at the facility. On 01/25/2024 at 12:45 PM, a Certified Nursing Assistant (CNA) verbalized R155 asked why the Administrator was moving a recliner, voicing it was the only place the resident could sit outside of their room. The CNA verbalized the Administrator told the resident, if this place doesn't feel comfortable, and is not on your level, get out of here. The CNA reported R155 began crying. The CNA verbalized facility process would be to report to the Abuse Coordinator, however; the CNA did not report the abuse because the Abuse Coordinator witnessed the event. The CNA indicated abuse can be verbal and considered what the Administrator said to be abuse. On 01/25/2024 at 1:51 PM, the Deputy Director reported R155's family member submitted a complaint regarding the Administrator's comments on 01/20/2024. Based upon the information provided in the complaint, the Deputy Director indicated the incident met the criteria for verbal abuse and directed the facility to open an investigation. The Administrator was prohibited from interacting with residents during the investigation in lieu of suspension. The Deputy Director indicated the Abuse Coordinator and Administrator were mandated reporters and there was an expectation for the facility to investigate potential abuse immediately. On 01/25/2024 at 2:58 PM, the Administrator reported while conducting rounds on 01/09/2024, R155 was encountered outside of the resident's room complaining about the care and about the Administrator. The Administrator responded to R155 by stating if you don't like the care there are other facilities you can go to. The Abuse Coordinator stepped in to address the resident and the Administrator returned to their office. The Administrator indicated residents were not informed furniture was scheduled for removal from the common area and explained, the furniture doesn't belong to them. Mental Abuse Resident 155 (R155) R155 was admitted on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS), post-traumatic stress disorder, and motor neuron disease. A Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. On 01/23/2024 at 1:38 PM, R155 verbalized there was an altercation between the resident and the facility Administrator on 01/09/2024. The Administrator and two maintenance personnel removed pictures from the wall and furniture, including a recliner, from the common area outside R155's room. R155 advised had told the Administrator would be better to talk to the residents and ask them how they feel about the furnishing. R155 indicated the Administrator did not respond and walked away. The resident verbalized the Administrator returned with the Abuse Coordinator and continued to remove furniture. On 01/25/2024 at 11:22 AM, the Abuse Coordinator revealed had spoken with the resident and the resident's family member who were both concerned about a chair R155 sat on outside the resident's room. The Abuse Coordinator revealed the resident had never been noted to be agitated before. On 01/25/2024 at 11:32 AM, R155 indicated the Administrator's actions hit a nerve related to R155's experiences in Vietnam. The resident expressed the removal of the recliner was upsetting as it was the only location outside the resident's room where R155 could be seated comfortably due to a diagnosis of ALS which limited the resident's mobility in both arms and legs. R155 reported feeling disrespected and helpless watching staff move the recliner without discussing it with the resident. The recliner provided R155 the ability to remain engaged in their surroundings and expressed feeling a loss of autonomy without the recliner. After the recliner was removed the resident was sat in a transport wheelchair which resulted in an obstructed view limiting R155's engagement with other residents. R155 verbalized concerns of being insulted in public. FRI #NV00070286 FRI #NV00070265

Based on observation, interview, record review, and document review, the facility failed to develop a baseline care plan within 48 hours of admission for a resident using a brace (a medical device used to prevent unwanted movement in a joint), for 1 of 31 sampled residents (Resident 141). The deficient practice had the potential to delay or prevent the provision of needed care to the resident, which could result in adverse mental or physical outcomes for the resident. Findings include: Resident 141 (R141) R141 was admitted on [DATE] with diagnoses including fracture of the lower end of the right femur (thigh bone). On 01/23/24 at 10:12 AM, R141 was supine in bed and answered questions appropriately. R141 reported being confined to bed most of the time. The resident recalled undergoing surgery for a thigh bone fracture occurring just above the right knee, with implanted hardware. R141 reported following surgery a brace had been applied to the right leg, and the resident had subsequently been transferred from the hospital to the nursing facility still wearing the brace on the right leg. R141 revealed since admission to the nursing facility several months prior, the brace has remained on the right leg most of the time. The resident reported the brace had been removed and then reapplied by nursing staff at irregular intervals. The resident reported when the brace was off noticing the skin of the leg underneath the brace looked roughened. The resident verbalized it looked like snakeskin. The resident reported feeling concerned about harm to the skin resulting from prolonged wearing of the brace. R141 stated while not painful, the brace was uncomfortable, and the resident would prefer not to have it on the leg. A review of R141's medical revealed the following: A physician's progress note dated 01/22/2024, indicated R141 was admitted to an acute care hospital on 7/29/2023 after a slip and fall in the shower. An orthopedic consultation was completed, and the resident underwent surgical fixation of the right femur on 7/29/2023. The Nursing Admission assessment dated [DATE], documented the resident was bedbound with s/p ORIF (status/post open reduction internal fixation) with brace. The Admission Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] and the Quarterly MDS dated [DATE], both revealed the resident had good memory function and required staff assistance for all activities of daily living, and used a wheelchair for mobility. The MDS assessments lacked documentation the resident used a brace. A handwritten orthopedic consultation note dated 12/28/2023 indicated R141 was seen at a medical office located off of the facility campus by a physician's assistant (PA). The examination notes indicated the resident had no active range of motion, and was scared to move the right leg. X-rays revealed fracture non-union, with hardware well-placed. The assessment and plan documented may stand to transfer; use knee brace when up and daily physical and occupational therapy. The note lacked documented evidence a staff member had read or acted upon the assessment and plan recommendations. R141's medical record lacked a physician's order for use of the brace. A current care plan for mobility indicated a problem of limitations related to recent fracture and surgery on the right femur as manifested by requiring assistance with rolling left and right, sitting to lying, lying to sitting, sit to stand, chair to bed transfer, toilet and tub or shower transfer, walking, and wheelchair mobility. R141's care plans lacked documentation regarding use of the brace. On 01/30/2024 at 10:35 AM, the Director of Rehabilitation Services conducted a review of R141's electronic health record regarding R141's use of a brace. The Director of Rehabilitation Services revealed not being aware the resident used a brace. The Director of Rehabilitation Services verbalized recent therapy notes lacked any documentation of a brace. The Director of Rehabilitation Services revealed R141's initial PT evaluation, performed shortly after admission (the exact date was not obtained) documented the resident had a current orthotic device knee brace, not ordered by therapy. The Director of Rehabilitation Services indicated after noting the brace during the initial assessment, the established procedure would be for the therapist to discuss the use of the brace with nursing staff, and jointly develop a care plan. The Director of Rehabilitation Services verbalized the record review indicated the established procedure had not been followed. On 01/30/2024 at 11:18 AM, the resident was supine in bed. An observation was conducted accompanied by the Director of Rehabilitation Services, the Charge Nurse, the Sidewinder Unit Nurse Manager, and the Licensed Practical Nurse (LPN). With the resident's permission, the bedclothes were moved aside by the LPN to reveal the resident was wearing a brace on the right leg with the leg extended straight and the ankle supported on a pillow. The brace itself was about two feet long, made of a thick dark colored fabric material such as nylon, which formed a cylindrical tube around the resident's right leg from about mid-thigh to about the middle of the right calf, encompassing the right knee joint. The device had four individual Velcro fasteners which secured a slit which ran down the full length of the brace. On 01/30/2024 at 11:18 AM, the Velcro straps were loosened, and the brace was removed by the Charge Nurse and the LPN, revealing small white flakes consistent with dried skin on the surface of the resident's leg and also adhering to the interior of the brace. There were scattered small pits or dents on the areas which had been covered by the brace, some with faint purplish coloration, consistent with areas where the brace had been in contact with the resident's leg. The Director of Therapy, the Charge Nurse, the Unit Manager, and the LPN, present in the room and all having observed the resident, verbalized they had not been aware of the brace. All verbalized the brace should not be on the resident while the resident was in bed. On 01/30/2024 at 11:22 AM, the Charge Nurse verbalized when caring for a resident using a device such as a brace, the device should be removed, and the skin and circulation assessed by a licensed nurse or a therapist at least once every shift. The Charge Nurse verbalized not knowing how often or by whom the brace had been removed and the leg assessed prior to the observation made today. On 01/30/2024, around noon, the Sidewinder Unit Nurse Manager conducted a record review of R141's medical record. The Sidewinder Unit Manager verbalized the record lacked a baseline care plan for the brace. The Sidewinder Unit Nurse Manager explained upon admission, orders supplied by the transferring hospital would be re-written by the admitting provider. After a provider wrote the order, the MDS nurse would then develop a baseline care plan for a device such as a brace. The Sidewinder Unit Nurse Manager acknowledged this process had not been followed. The Sidewinder Unit Nurse Manager verbalized failure to develop and implement a care plan could have negative consequences for the resident, including potential skin breakdown, and if the brace was left on for a long period of time the skin breakdown could be very severe. On 01/30/2024 at 2:31 PM, the Certified Nurse Assistant (CNA) verbalized working the day shift (6:30 AM to 2:30 PM). The CNA verbalized when arriving at work, an inter-shift face to face report was conducted upon arrival to update care for residents on the assigned group of residents. The CNA verbalized being assigned to R141 today for day shift. The CNA indicated had seen the brace on R141's right leg but had not disturbed it as they had not received any instructions from the licensed nurse or off-going CNA regarding the brace. The CNA verified the resident had been received in bed with the brace on. The CNA verbalized an understanding braces may need to be removed for bathing or to check the circulation every two hours, but lacking instructions felt the licensed nursing or therapy staff were assessing the condition of the resident's skin and circulation under the brace. The policy and procedure titled Care Planning, revised 04/24/2014, indicated the resident's interim care plan would be initiated upon admission. The policy indicated all problems and needs would be identified and care planned. Interventions and approaches would be listed and implemented.

Based on interview, record review and document review, the facility failed to ensure a comprehensive care plan for post-traumatic stress disorder (PTSD) was developed for 1 of 31 sampled residents (Resident 149). The deficient practice had the potential for the resident not receiving person-centered care and services. Findings include: Resident 149 (R149) R149 was admitted on [DATE], with diagnoses including post-traumatic stress disorder (chronic) and anxiety disorder. The Admission Summary Nurse's Notes dated 12/13/2023, documented R149 had helicopter-triggered PTSD. R149's Admission Minimum Data Set (MDS) dated [DATE], documented the resident's active diagnoses including PTSD and anxiety disorder. R149's medical record lacked documented evidence a comprehensive care plan for the resident's PTSD was developed. On 01/30/2024 at 12:45 PM, the MDS Coordinator confirmed the findings and revealed R149's MDS admission assessment was completed on 12/26/2023. The MDS Coordinator explained the comprehensive care plan should have been completed within seven days or on 01/02/2024. The MDS Coordinator acknowledged R149's comprehensive care plan should have included PTSD and should have been person-centered. The facility's policy titled Care Planning dated 04/24/2019, documented comprehensive care plan would have been completed by the MDS nurse and members of the inter-disciplinary team. Comprehensive care plan would have been completed no later than seven days following the close date of the Admission MDS, significant change MDS, and annual MDS. All problems, needs, and risks would have been identified under the problem section. The problem would have been personalized and specific to the resident.

Based on observation, interview, record review, and document review, the facility failed to obtain a physician order or to assess a brace (a medical device used to prevent unwanted movement in a joint), for 1 of 31 sampled residents (Resident 141). The deficient practices had the potential to result in damage to the resident's affected joint, and/or impaired circulation and resultant tissue damage to the extremity. Findings include: Resident 141 (R141) R141 was admitted on [DATE] with diagnoses including fracture of the lower end of the right femur (thigh bone). On 01/23/24 at 10:12 AM, R141 was supine in bed and answered questions appropriately. R141 reported being confined to bed most of the time. The resident recalled undergoing surgery for a thigh bone fracture occurring just above the right knee, with implanted hardware. R141 reported following surgery a brace had been applied to the right leg, and the resident had subsequently been transferred from the hospital to the nursing facility still wearing the brace on the right leg. R141 revealed since admission to the nursing facility several months prior, the brace has remained on the right leg most of the time. The resident reported the brace had been removed and then reapplied by nursing staff at irregular intervals. The resident reported when the brace was off noticing the skin of the leg underneath the brace looked roughened. The resident verbalized it looked like snakeskin. The resident reported feeling concerned about harm to the skin resulting from prolonged wearing of the brace. R141 stated while not painful, the brace was uncomfortable, and the resident would prefer not to have it on the leg. A review of R141's medical revealed the following: A physician's progress note dated 01/22/2024 indicated R141 was admitted to an acute care hospital on 7/29/2023 after a slip and fall in the shower. An orthopedic consultation was completed and the resident underwent surgical fixation of the right femur on 7/29/2023. The Nursing Admission assessment dated [DATE] documented the resident was bedbound with s/p ORIF (status/post open reduction internal fixation) with brace. The Admission Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] and the Quarterly MDS dated [DATE], both revealed the resident had good memory function and required staff assistance for all activities of daily living, and used a wheelchair for mobility. The MDS assessments lacked documentation the resident used a brace. A handwritten orthopedic consultation note dated 12/28/2023 indicated R141 was seen at a medical office located off of the facility campus by a physician's assistant (PA). The examination notes indicated the resident had no active range of motion, and was scared to move the right leg. X-rays revealed fracture non-union, with hardware well-placed. The assessment and plan documented may stand to transfer; use knee brace when up and daily physical and occupational therapy. The note lacked documented evidence a staff member had read or acted upon the assessment and plan recommendations. R141's medical record lacked a physician's order for use of the brace. On 01/30/2024 at 10:35 AM, the Director of Rehabilitation Services conducted a review of R141's electronic health record regarding R141's use of a brace. The Director of Rehabilitation Services revealed not being aware the resident used a brace. The Director of Rehabilitation Services verbalized recent therapy notes lacked any documentation of a brace. The Director of Rehabilitation Services revealed R141's initial PT evaluation, performed shortly after admission (the exact date was not obtained) documented the resident had a current orthotic device knee brace, not ordered by therapy. On 01/30/2024 at 11:18 AM, the Velcro straps of the resident's brace were loosened, and the brace was removed by the Charge Nurse and the LPN, revealing small white flakes consistent with dried skin on the surface of the resident's leg and also adhering to the interior of the brace. There were scattered small pits or dents on the areas which had been covered by the brace, some with faint purplish coloration, consistent with areas where the brace had been in contact with the resident leg. On 01/30/2024, around noon, the Sidewinder Unit Nurse Manager conducted a record review of R141's medical record. The Sidewinder Unit Manager verbalized the record lacked a physician's order for the brace. The Sidewinder Unit Nurse Manager explained upon admission, orders supplied by the transferring hospital would be re-written by the admitting provider. The Sidewinder Unit Nurse Manager acknowledged this process had not been followed. The Sidewinder Unit Nurse Manager verbalized failure to obtain a physician's order could have negative consequences for the resident, including potential skin breakdown, and if the brace was left on for a long period of time the skin breakdown could be very severe. The policy and procedure titled Physician Orders, revised 12/16/2019, indicated all orders for treatment and medication shall be written and signed by the provider. Rehabilitation treatment orders may be written by the therapist and would describe modalities of treatment.

Based on interview and document review the facility failed to 1) develop and implement a person-centered care plan to support dementia care needs and 2) develop individualized interventions related to symptoms of dementia for 1 of 31 sampled residents (R117). Findings include: Resident 117 (R117) R177 was admitted on [DATE] with diagnoses including dementia, major depressive disorder, and post-traumatic stress disorder. On 01/24/2024 at 9:41 AM, R177's medical record lacked documented evidence of a care plan or individualized interventions for dementia. A review of the most recent Minimum Data Set (MDS) section I documented R177 was coded with an active diagnosis of dementia. On 01/25/2024 at 9:41 AM, the MDS Manager Coordinator verbalized R117 required assistance with activities of daily living due to a compression fracture, was at risk for falls due to history, and had a hearing deficit. Potential for mood problems manifested as difficulty falling asleep and lethargy. The MDS Manager Coordinator confirmed R117 did not have a care plan for dementia. On 01/26/2024 at 8:34 AM, The Director of Nursing (DON) revealed the expectation to develop a care plan was based on either the resident's symptoms or diagnosis. On 01/30/2024 at 11:21 AM, a Licensed Practical Nurse (LPN) verbalized a resident's care plan determines what interventions are most appropriate for the resident's dementia care needs. If a resident did not have a care plan for an identified problem the LPN would alert the Nurse Supervisor. On 01/30/2024 at 11:32 AM, a Certified Nursing Assistant indicated staff are alerted to resident's interventions by reviewing the care plan. The Nursing Policy and Procedure Manual for care planning revised 4/24/2019 documented all problems and risks will be identified under the problem section. The problem will be personalized and specific to the resident.

Based on interviews and record review, the facility failed to ensure the resident received adequate supervision to prevent accidents for 1 of 16 sampled residents. (Resident #4). Findings include: Resident #4 Record Review: Resident #4 was admitted on [DATE], with the following Diagnoses: [REDACTED]. Review of the quarterly progress note, dated 7/3/13 stated, "(Name of resident) is (age of resident) who is alert and oriented to self only as evident by his inability to recall time, place or date. Resident is still able to recognize his wife. His allergies [REDACTED].(Name of resident) also is on continuous O2 (oxygen). (Name of resident) is out of bed daily and uses a w/c (wheelchair) for mobility. He has a tray on his wheelchair due to his falling. This is new this last quarter. (Name of resident's) vision is adequate with glasses. Resident's hearing is somewhat poor and he does have hearing aids. Speech is clear and resident is able to make some of his needs known but, staff anticipates the rest for him. (Name of resident) eats in the Cove neighborhood. He needs supervision at meal time with some cueing depending on the day and time. (Name of resident) naps after lunch for more or less an hour depending on the day. He is a pleasant and cooperative person most of the time. His family is very supportive of all his needs. It is very important for him to sit outside when weather permits." On 7/15/13 at 2:45 PM, the LPN (licensed practical nurse) documented: "Patient was found outside back yard, w/c (wheelchair) had front wheel stuck on grass, he was slumped over, Patient was assisted to his room, very warm to touch, sweating, able to respond to name. RN (registered nurse) was called to unit immediate charge nurse and supervisor. Vital signs BP 161/63, Temperature 101.9 degrees Fahrenheit orally, Oxygen saturation 90% with oxygen running at 2 Liters. Cool compresses applied, to forehead and body. Patient was able to open his eyes and respond, able to drink a few seeps (sic) of cool water. but he closes his eyes and is very sleepy. Paramedics and FNP (family nurse practitioner) were called immediately, we received orders to send Patient to (name of hospital). wife was notified of event and agrees to send Patient to hospital to be assessed. Patient was picked up at 13:50 PM (1:50 PM)." On 7/15/13 at 6:55 PM, registered nurse documented: "Late entry from 7/15/13 at 1350 (1:55 PM) Writer was called to resident's room. Resident was sitting up in his broda chair. CNA's removed his shirt and sleeve protectors; providing cooling measures, wash clothes to head, face, neck and torso. Resident is responsive; Alert and oriented x1 as usual for him, appears flush to face and neck. VS (vital signs): BP 161/63, Temperature 101.9 degrees Fahrenheit orally, Oxygen saturation 90% with oxygen running at 2 Liters. House supervisor arrived to resident's aid in addition to: 2 Cna's (certified nursing aides), LPN (licensed practical nurse). and Safety officer. Writer received telephone order from (name of family nurse practitioner) to send resident out to (name of hospital ER). 911 called with fire department) arriving within 5 minutes of being called. Resident safety transferred to (name of hospital ER) via gurney at 1350 (1:50 PM). Writer informed wife, wife thanked writer for requests that (name of this facility) keep her and her grandson informed." On 7/18/13, the facility's Director of the Social Services documented: "This investigation was prompted on 7/16/13 when a safety officer on rounds of perimeter of building reported to Mariner Cove Charge Nurse, (name of Charge Nurse), Resident #4 who was diagnosed with [REDACTED]. Staff immediately responded and discovered Resident #4's had the front of his wheelchair stuck in the grass alongside the paved sidewalk. Staff members brought Resident #4 inside the building and assessed his medical condition. Physician and family were notified of resident's medical condition and order was given to send resident to ER (emergency room ). Conclusion: During the investigation of this incident, it was discovered (name of Resident #4) was outside unmonitored for an extended period of time in extreme heat resulting in Heat stroke and blistering of his thighs. In addition, (Name of resident #4), a resident on the secured neighborhood had an assigned CNA (certified nursing aide) to monitor resident's safety in order this neglectful outcome." Plan of Care, dated 4-7-13, revealed: a wanderguard was applied to prevent elopement and promote safety. Review of the Plan of Care, dated 4/17/13, for Resident #4 stated: PROBLEMS/ CONCLUSIONS: Wander: wandering, elopement risk as evidenced by: exiting seeking; Resident wanders aimlessly, impaired safety awareness, disoriented to place. MEASURABLE GOALS: Resident safety (safety) will be maintained. (Review: 7/2/13) Resident will not leave facility unattended. (Review: 7/2/13) APPROACHES/ INTERVENTIONS: Personalize room with clock, calendar, signs or pictures. (Start: 4-17-13.) Safe walking path. (Start: 4-17-13) Outside secure courtyard for safe walking. (Start: 4-17/13) Check Resident's location every 15/30/60 minutes. (Start: 4-17-13) Staff to accompany Resident to (Start: 4-1713) Disguise Exits. (Start 4-17/13) Distract Resident from wandering by offering pleasant diversions, structured activities, food conversation, television, book. Toileting schedule. (Start: 4-17-13) Structured and supervised walking activities. (Start: 4-17-13) Reorientation to person, place and time PRN. (Start: 4-17-13) Maintain log of interventions that work. (Start: 4-17-13) Identification band on Resident's clothing. (Start: 4-17-13) Identify pattern of wandering: Is wandering purposely, aimless or escapist? Is Resident looking for something? Does it indicate the need for more exercise? (Start: 4-17-13) Document all Incidents of wandering. (Start: 4-17-13) Apply wanderguard to left wrist: Ensure for proper functioning daily. (Start: 4-17-13) Keep picture of Resident at front desk. (Start: 4-17-13) Assess for Fall Risk: (Start: 4-17-13) Monitor for fatigue and weight loss. (Start: 4-17-13) To reiterate, on 04/17/13, the facility identified on the Plan of Care, Resident #4 as a wanderer and an elopement risk and developed interventions to check resident's location every 15/30/60 minutes and approaches to protect the resident. Hospital Records: Resident #4 presentation to the ED (Emergency Department) when transported from the facility. On 7/15/13, the resident arrived at the emergency room . The chief complaint: left outside too long at the (name of the facility). Lethargic, nausea and vomit times one. Vital signs: B/P: 123/60, Temperature: 102 degrees Fahrenheit; Pulse: 78; Respiratory rate: 18. Saturation level 98% with 3 liters of oxygen. No respiratory distress; Pedal edema +2; Patient is drowsy, not answering most questions. Reddened skin darker red/ purple to right knee. On 7/15/13, Resident #4 was admitted to the inpatient unit at the hospital. The licensed nurse documented: Integumentary Findings: Abnormal: 3x2 cm (centimeter) fluid-filled blister on left thigh open to air; open blister on right thigh Stage II measuring 17x10 cm. with polymem dressing and abdominal pad that is clean, dry and intact; open blister on mid-back measuring 3x2 cm. with polymem dressing this is clean dry and intact; non blanchable [DIAGNOSES REDACTED] on left gluteus that is open to air. Interventions: Reinforce dressing, reposition, apply heel protectors, Administer medications as ordered. Review of the Plan of Care developed on dated 7/16/13 after Resident #4 was found outside of the building stated: PROBLEMS/ CONCLUSIONS: (name of resident) loves the outdoor and will stay in the patio during day time. He tends to forget to return inside: Alzheimer's. He is at risk for the effects of weather changes such as elevated temperatures, increasing confusion and weakness. MEASURABLE GOALS: (name of resident) will continue to enjoy the outdoors with staff supervision to ensure safety at all times. APPROACHES/ INTERVENTIONS: Outside patio door will be kept close at all times when temperature is 90 degrees and above. Staff to monitor doors every shift. Patio doors thermometer will be checked every shift for temperature reading accuracy and will be replaced as needed. (start: 7-16-13). Staff to escort (name of resident) in going out to the patio and staff to escort him back to the unit within 15 to 20 minutes. If (name of resident) wishes to stay longer, staff is to stay with him. (Start: 7-16-13). Offer (name of resident) fluids (Start: 7-16-13) Explain to (name of resident) the reasons he cannot go out when the temperature is higher 100 degrees and above. (Start 7-16-13). Offer alternative activities inside the facility in Town Square. Charge nurse to inform the family if (name of resident) refuses to return inside during extreme weather. Enforce watcher program every shift, charge nurse to monitor CNAs compliance. (Start: 7-16-13) (Note: The 07/16/13 Plan of Care was developed after the resident was transferred to the hospital in anticipation of Resident #4 returning, however Resident #4 did not return to the facility (thus was not implemented.)) Required Self-Report of Incident to State Agency: The initial faxed received date to this State Agency was 07/19/13. The facility submitted an initial and final self report as required per the State and Federal guidelines for reporting injuries. Review of the the effective components of the corrective action plan were to conduct increased supervisory observation rounds of the residents to an hourly rate and to identify the high risk residents to have increase monitoring onto a (Outside) watch list. The facility's Immediate Plan of Correction stated: "7. We have increased rounds by safety personnel to the interior patios and exterior grounds of this building to hourly. 8. We have compiled an "outside watch list" (attachment: g) of residents that go outside and Instructed CNA's responsible for oversight of the resident to condict (sic) more frequent verification of their whereabouts. Nurse managers will follow-up as a second check for the identified residents. All staff have been instructed to be extra vigilant during extreme heat to monitor residents. A policy was also submitted with the self report, which included: The facility's Policy #: DRAFT effective 7/16/13 - SUBJECT: Excessive Heat Precautions POLICY: To protect our Residents during periods of excessive heat. PROCEDURE: 1. Cove Patio Doors a. The Cove patio doors will be locked once the outside temperature exceeds 90 degrees. b. No residents will be permitted to go outdoors during this time without direct supervision at all times. c. Once temperatures drop below 90 degrees the charge nurse or nurse manager will assess the safety of residents returning to the patio. 2. Patio gates will be locked on all neighborhoods when temperatures exceed 90 degrees. a. For resident safety, resident wanting to go outside may use the main front entrance to enter and exit the facility; his (sic) will allow staff to better track residents exiting the facility and track how long residents spend in the heat. a. A staff member will be assigned to monitor the main entrance during the periods of excessive heat to better track residents for safety purposes. Interviews: On 8/8/12 at 2:45 PM, the Performance Improvement Nurse indicated there were no policies related to heat warnings prior to the incident. The nurses used their judgement. The nurses closed doors when temperatures were high outside. The RN indicated, she noticed and heard nurses on the Cove talk to residents about the extreme weather and the need to close the doors to the outside. During an interview, the CNA on the Sidewinder unit revealed there was no official list of residents on a (Outside) Watch List. She further explained that CNAs on the Sidewinder unit are responsible for their assigned residents and watch over the other residents on the unit as needed. On 8/9/13 at 1:45 PM, the unit secretary from the Sidewinder unit was interviewed. The secretary was asked about the Outside Watch List. She printed a list of residents from all units of the building (Sidewinder, Mariner, Cove, and Falconer) and that the list identified residents who were on a Wander List. She was unfamiliar with, and was not able to provide, the Outside Watch List. Review of the list of residents on the Outside Watch List provided by Administration, which included: 4 residents from the Mariner unit; 11 residents from the Sidewinder unit and 2 residents from the Falconer unit. On 8/9/13, a random review of the CNA communication assignment sheets on the Sidewinder and the Falconer units did not identify for the CNA who was on the Outside Watch List. (Note: The facility was observed conducting increased rounds by the safety personnel to the interior patios and exterior patios of the building hourly.) Summary: The above observations, interviews and review of the documentation revealed that the summation of the staff's efforts was inadequate in providing preventive and protective supervision for Resident #4 from being over exposed to the sun/heat. Also, the facility's proposed corrective actions were not sufficiently implemented to prevent possible injury to all residents (the facility only identified high risk residents for protection and the basis for their selection was not clearly defined).

Based on interview, clinical record review, document review, and policy review, the facility failed to take appropriate measures to prevent further instances of abuse by a visitor after the visitor had abused a resident for 2 of 6 sampled residents (Residents #1 and #2). Findings include: The facility's policy titled, "Resident Abuse", Policy #G-1201, dated 09/13/2012, stated in part:... "Team members must immediately report all incidents of suspected, potential, or known mistreatment, neglect, or abuse, and misappropriation of resident property to the Administrator or designee. The Administrator or designee must report these incidents to the appropriate State Agencies within 24 hours... Each incident will be thoroughly investigated, within 5 days... All team members and witnesses involved, including residents, shall be interviewed as appropriate. Signed and dated statements shall be obtained, when possible... If the investigation indicates that a crime has been committed, the Boulder City Police Department will be contacted, immediately". Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation reviewed indicated Resident #2's family member slapped resident #2 on 02/17/2013 at 3:30 PM on the left leg. The family member slapped Resident #2 at 4:30 PM on the left side of the face. The family member again slapped the resident in the mouth on 02/17/2013 at 5:30 PM. Documentation indicated Resident #2's family member slapped Resident #1 on the hand on 02/18/2013 at 12:55 PM. Resident #1 & Resident #2: Resident #2's Progress Note written by Employee #14, a licensed nurse, dated 02/17/2013 at 10:14 PM, stated in part, ""...At (3:30 PM), LPN and CNA's observed (resident's) (family member) trying to bend (resident's) knee, which was stiff, to put foot on (wheelchair) pedal. When (resident) did not comply with (family member) she called (resident) a jerk and forced (resident's) foot on (wheelchair) pedal. This episode happened in TV room by nurses station. Reported to charge nurse at that time. At (4:30 PM), LPN and CNA's observed resident's (family member) open hand slap (resident) to left side of face. No bruising or impression observed. At (5:30 PM) during supper, CNA was feeding (resident when family member) grabbed staff's hand to force feed (resident). CNA asked (family member) to stop and (family member) did at that time. (Resident) also yelled 'NO' when another bite of food was coming near his mouth and (family member) slapped him in the mouth. CNA told (family member) not to do that. LPN reported episodes to charge nurse and supervisor was made aware. Family member also called LPN a jerk for not letting her feed Resident #2. Explained to (family member) that (resident) if (sic) high risk for aspiration. Resident's (family member) walked away and talked to charge nurse regarding (sic) feeding. Will (continue) to monitor". On 02/17/2013, Employee #14 documented for the investigation, "(At 3:30 PM) myself and 2 CNA's observed resident's family member (Resident #2's family member) trying to bend (resident's) knee to put foot on (wheelchair) pedal When (resident) didn't comply, (family member) forced Resident #2's foot on (wheelchair) pedal & called him a jerk in TV room. (At 4:30 PM) myself & 1 CNA observed (Resident #2's family member) open hand slap to left side of face. (At 5:30 PM), CNA was feeding (resident) in dining area when (family member) grabbed CNA's hand to force feed (resident). (Resident) also yelled 'no' when another bite of food was coming near his mouth and (family member) slapped (resident) in the mouth. CNA told (family member) not to do that. I reported episodes to charge nurse & supervisor aware. (Resident #2's family member) also called LPN a jerk". On 02/17/2013, Employee #18, a CNA, documented for the investigation, "At about 3:30 PM today I witnessed (Resident #2's family member) yell at (Resident #2) to bend his knee and put his foot on the foot pedal. When he wouldn't she yelled at him telling him he was a jerk and to stop being a jerk. She then slapped him on the left leg saying 'bend your knee you jerk'. At dinner time I sat down to feed (Resident #2). As I was giving him a bite (Resident #2's family member) grabbed my hand and tried forcing the spoon into his mouth. I pulled my hand away and she told me to let her help me because he knows her better. A few minutes later I went to give (Resident #2) another bite, he yelled out no and that's when (Resident #2's wife) slapped him in his mouth and told him that he needs to take another bite and not yell like that". On 02/17/2013, Employee #15, a CNA, documented, "At approximately 4:30 while i, (CNA's name) was on duty, i witnessed (Resident #2's wife) slap (Resident #2) across the left cheek, while she appeared to be scolding him". Employee #15 was interviewed on 06/03/2013, at 2:38 PM. He was asked if Resident #2's wife "slapped" him or gave him a "Love Tap". He stated Resident #2's wife gave him a "full fledged slap". On 06/11/2013, at 8:30 AM, the Social Worker from Resident #2's hospice was interviewed. She stated she was called by staff after Resident #2 was struck in the face twice and on his legs once. She stated she assessed Resident #2 and questioned him, and he did not recall being slapped. She stated she told the facility Social Worker the incident needed to be reported to the appropriate authorities. The hospice Social Worker indicated she reported the abuse to the authorities. Resident #2's Hospice documentation was reviewed on 06/11/2013. The Social Work Clinical Note, dated 02/17/2013, stated in part, "Social Worker received call stating (Patient) was sitting (with) his wife in a common area of the facility. She slapped his body (legs) and later open-handed slapped him in the face. This was observed by staff (Employee #14). (Patient's) wife also attempted to force him to eat when he refused. Wife left prior to (Hospice Social Worker and Nurse) arrival. Incidents occurred between 3:30 PM and 6 PM, when she voluntarily left. Per staff her son left the facility to return to (California); wife will remain in Las Vegas through (Tuesday) when she returns to Reno, (Nevada). Wife is a Federal Judge and must return to work on Tuesday...". On 06/11/2013, at 1:30 PM, Employee #17, the Social Worker on call on 02/17/2013, was interviewed. She stated she was not notified of Resident #2's wife slapping Resident #2 until approximately 7:00 PM on 02/17/2013, after the three slapping instances occurred to Resident #2. She stated she spoke to the House Supervisor and ensured Resident #2's wife had left the premises. She stated she was told Resident #2 would be with his own CNA for the rest of the night "1:1" (one CNA to Resident #2). She stated she spoke with the Social Worker from the Hospice and both Social Workers agreed to report the instances to the appropriate agencies. The facility Resident #1's clinical record was reviewed on 05/31/2013. Her Plan of Care stated that on 02/18/2013, she "attempted to pick up another person's purse that was sitting on the floor. The person who the purse belonged to slapped (Resident #1's) hand away, pushed the wheelchair backward, and stated, 'That's not yours. Put it down. Get out of here'. No injury noted". On 06/07/2013 at 3:45 PM, Employee #16, a licensed nurse, was interviewed. She stated she observed Resident #1 propel her wheelchair close to Resident #2's wife and grab at her purse. She indicated from her vantage point, she did not see Resident #2's wife slap the resident, but the Certified Nurse Assistant had witnessed the event and reported to her. Resident #2's Progress Note, dated 02/18/2013 at 1:13 PM, stated in part, "...@1255 one of the resident (sic) unknowingly tried to pick up (Resident #2's wife) purse and she pushed the resident away, slapped her hand and told her that it's not yours and go away, don't come over here. House Supervisor notified and has arrived to the unit. Mariner Social Worker has been contacted by the House Supervisor. (Resident #2's Hospice) RN and (Resident #2's Hospice) Social Worker present during the event and is currently counseling (Resident #2's wife). Resident has been removed from the immediate area and interventions to ensure safety of other residents on the unit currently underway". Resident #2's Progress Note, dated 03/08/2013 at 10:59 AM, indicated the Nurse Manager of Resident #1 and Resident #2's unit, and the Social Service Director, had a meeting with Resident #2's wife. The document stated in part, "...to establish boundaries prior to her next scheduled visit on the 13th of this month. Informed (Resident #2's wife) future visits will be supervised, no aggressive touching of her husband or other residents, and staff members will need to feed resident only. If these boundaries are not adhered to or if her actions interfere with the care of her husband have been authorise (sic) to contact the police". The facility's Director of Social Services at the facility documented (undated), "Meeting held today with (Resident #2's wife). (Administrator, Nurse Manager, Director of Nursing and Social Services Director) in attendance to discuss events surrounding incident with her husband and (Resident #1). (Resident #2's wife) stated she just gave (Resident #1) a light tap to stop her from reaching for purse. (Resident #2's wife) also stated the interaction between herself and her husband is how they relate to each other and they have related like this over the years. It was just a 'Love Tap'. Explained to (Resident #2's wife) in skilled nursing care the rules of family interactions do change at times. (Resident #2's wife) stated she felt she did nothing wrong". On 06/03/2013, at 12:37 PM, the Social Services Director was interviewed. She stated the meeting to discuss the incidents on 02/17/2013 and 02/18/2013, involving Residents #1 and #2, was attended by the Social Services Director, the Director of Nursing, and Unit Manager, and the Administrator. She stated those in attendance at the meeting agreed the slappings were "physical abuse". She acknowledged the intervention to "monitor" Resident #2's wife after the first slap she committed were not effective and did not prevent further abusive instances. She stated the police were not called. She stated she did not think the slappings were "a crime". She stated if there were a "severe injury" the police would have been called. She stated Resident #2's wife considered the meeting "an insult". She acknowledged there was no documentation attempts were made to interview Residents #1 & #2. On 06/11/2013, at 9:00 AM, the facility Administrator was interviewed. He stated he was not made aware of the incidents of abuse until 02/19/2013. He also indicated the police should have been called, and the facility intended to change the Abuse Policy to reflect that the police would be called for all instances of abuse. He indicated when staff met with Resident #2's wife to discuss the incidents, she joked the facility staff was "slapping her hand". Based on the findings of this investigation, the allegation of abuse was substantiated. NV 502

2 Based on interviews and record review, the facility failed to ensure the resident received adequate supervision to prevent accidents for 1 of 16 sampled residents. (Resident #4). Findings include: Resident #4 Record Review: Resident #4 was admitted on [DATE], with the following Diagnoses: [REDACTED]. Review of the quarterly progress note, dated 7/3/13 stated, (Name of resident) is (age of resident) who is alert and oriented to self only as evident by his inability to recall time, place or date. Resident is still able to recognize his wife. His allergies [REDACTED].(Name of resident) also is on continuous O2 (oxygen). (Name of resident) is out of bed daily and uses a w/c (wheelchair) for mobility. He has a tray on his wheelchair due to his falling. This is new this last quarter. (Name of resident's) vision is adequate with glasses. Resident's hearing is somewhat poor and he does have hearing aids. Speech is clear and resident is able to make some of his needs known but, staff anticipates the rest for him. (Name of resident) eats in the Cove neighborhood. He needs supervision at meal time with some cueing depending on the day and time. (Name of resident) naps after lunch for more or less an hour depending on the day. He is a pleasant and cooperative person most of the time. His family is very supportive of all his needs. It is very important for him to sit outside when weather permits. On 7/15/13 at 2:45 PM, the LPN (licensed practical nurse) documented: Patient was found outside back yard, w/c (wheelchair) had front wheel stuck on grass, he was slumped over, Patient was assisted to his room, very warm to touch, sweating, able to respond to name. RN (registered nurse) was called to unit immediate charge nurse and supervisor. Vital signs BP 161/63, Temperature 101.9 degrees Fahrenheit orally, Oxygen saturation 90% with oxygen running at 2 Liters. Cool compresses applied, to forehead and body. Patient was able to open his eyes and respond, able to drink a few seeps (sic) of cool water. but he closes his eyes and is very sleepy. Paramedics and FNP (family nurse practitioner) were called immediately, we received orders to send Patient to (name of hospital). wife was notified of event and agrees to send Patient to hospital to be assessed. Patient was picked up at 13:50 PM (1:50 PM). On 7/15/13 at 6:55 PM, registered nurse documented: Late entry from 7/15/13 at 1350 (1:55 PM) Writer was called to resident's room. Resident was sitting up in his broda chair. CNA's removed his shirt and sleeve protectors; providing cooling measures, wash clothes to head, face, neck and torso. Resident is responsive; Alert and oriented x1 as usual for him, appears flush to face and neck. VS (vital signs): BP 161/63, Temperature 101.9 degrees Fahrenheit orally, Oxygen saturation 90% with oxygen running at 2 Liters. House supervisor arrived to resident's aid in addition to: 2 Cna's (certified nursing aides), LPN (licensed practical nurse). and Safety officer. Writer received telephone order from (name of family nurse practitioner) to send resident out to (name of hospital ER). 911 called with fire department) arriving within 5 minutes of being called. Resident safety transferred to (name of hospital ER) via gurney at 1350 (1:50 PM). Writer informed wife, wife thanked writer for requests that (name of this facility) keep her and her grandson informed. On 7/18/13, the facility's Director of the Social Services documented: This investigation was prompted on 7/16/13 when a safety officer on rounds of perimeter of building reported to Mariner Cove Charge Nurse, (name of Charge Nurse), Resident #4 who was diagnosed with [REDACTED]. Staff immediately responded and discovered Resident #4's had the front of his wheelchair stuck in the grass alongside the paved sidewalk. Staff members brought Resident #4 inside the building and assessed his medical condition. Physician and family were notified of resident's medical condition and order was given to send resident to ER (emergency room ). Conclusion: During the investigation of this incident, it was discovered (name of Resident #4) was outside unmonitored for an extended period of time in extreme heat resulting in Heat stroke and blistering of his thighs. In addition, (Name of resident #4), a resident on the secured neighborhood had an assigned CNA (certified nursing aide) to monitor resident's safety in order this neglectful outcome. Plan of Care, dated 4-7-13, revealed: a wanderguard was applied to prevent elopement and promote safety. Review of the Plan of Care, dated 4/17/13, for Resident #4 stated: PROBLEMS/ CONCLUSIONS: Wander: wandering, elopement risk as evidenced by: exiting seeking; Resident wanders aimlessly, impaired safety awareness, disoriented to place. MEASURABLE GOALS: Resident safety (safety) will be maintained. (Review: 7/2/13) Resident will not leave facility unattended. (Review: 7/2/13) APPROACHES/ INTERVENTIONS: Personalize room with clock, calendar, signs or pictures. (Start: 4-17-13.) Safe walking path. (Start: 4-17-13) Outside secure courtyard for safe walking. (Start: 4-17/13) Check Resident's location every 15/30/60 minutes. (Start: 4-17-13) Staff to accompany Resident to (Start: 4-1713) Disguise Exits. (Start 4-17/13) Distract Resident from wandering by offering pleasant diversions, structured activities, food conversation, television, book. Toileting schedule. (Start: 4-17-13) Structured and supervised walking activities. (Start: 4-17-13) Reorientation to person, place and time PRN. (Start: 4-17-13) Maintain log of interventions that work. (Start: 4-17-13) Identification band on Resident's clothing. (Start: 4-17-13) Identify pattern of wandering: Is wandering purposely, aimless or escapist? Is Resident looking for something? Does it indicate the need for more exercise? (Start: 4-17-13) Document all Incidents of wandering. (Start: 4-17-13) Apply wanderguard to left wrist: Ensure for proper functioning daily. (Start: 4-17-13) Keep picture of Resident at front desk. (Start: 4-17-13) Assess for Fall Risk: (Start: 4-17-13) Monitor for fatigue and weight loss. (Start: 4-17-13) To reiterate, on 04/17/13, the facility identified on the Plan of Care, Resident #4 as a wanderer and an elopement risk and developed interventions to check resident's location every 15/30/60 minutes and approaches to protect the resident. Hospital Records: Resident #4 presentation to the ED (Emergency Department) when transported from the facility. On 7/15/13, the resident arrived at the emergency room . The chief complaint: left outside too long at the (name of the facility). Lethargic, nausea and vomit times one. Vital signs: B/P: 123/60, Temperature: 102 degrees Fahrenheit; Pulse: 78; Respiratory rate: 18. Saturation level 98% with 3 liters of oxygen. No respiratory distress; Pedal edema +2; Patient is drowsy, not answering most questions. Reddened skin darker red/ purple to right knee. On 7/15/13, Resident #4 was admitted to the inpatient unit at the hospital. The licensed nurse documented: Integumentary Findings: Abnormal: 3x2 cm (centimeter) fluid-filled blister on left thigh open to air; open blister on right thigh Stage II measuring 17x10 cm. with polymem dressing and abdominal pad that is clean, dry and intact; open blister on mid-back measuring 3x2 cm. with polymem dressing this is clean dry and intact; non blanchable [DIAGNOSES REDACTED] on left gluteus that is open to air. Interventions: Reinforce dressing, reposition, apply heel protectors, Administer medications as ordered. Review of the Plan of Care developed on dated 7/16/13 after Resident #4 was found outside of the building stated: PROBLEMS/ CONCLUSIONS: (name of resident) loves the outdoor and will stay in the patio during day time. He tends to forget to return inside: Alzheimer's. He is at risk for the effects of weather changes such as elevated temperatures, increasing confusion and weakness. MEASURABLE GOALS: (name of resident) will continue to enjoy the outdoors with staff supervision to ensure safety at all times. APPROACHES/ INTERVENTIONS: Outside patio door will be kept close at all times when temperature is 90 degrees and above. Staff to monitor doors every shift. Patio doors thermometer will be checked every shift for temperature reading accuracy and will be replaced as needed. (start: 7-16-13). Staff to escort (name of resident) in going out to the patio and staff to escort him back to the unit within 15 to 20 minutes. If (name of resident) wishes to stay longer, staff is to stay with him. (Start: 7-16-13). Offer (name of resident) fluids (Start: 7-16-13) Explain to (name of resident) the reasons he cannot go out when the temperature is higher 100 degrees and above. (Start 7-16-13). Offer alternative activities inside the facility in Town Square. Charge nurse to inform the family if (name of resident) refuses to return inside during extreme weather. Enforce watcher program every shift, charge nurse to monitor CNAs compliance. (Start: 7-16-13) (Note: The 07/16/13 Plan of Care was developed after the resident was transferred to the hospital in anticipation of Resident #4 returning, however Resident #4 did not return to the facility (thus was not implemented.)) Required Self-Report of Incident to State Agency: The initial faxed received date to this State Agency was 07/19/13. The facility submitted an initial and final self report as required per the State and Federal guidelines for reporting injuries. Review of the the effective components of the corrective action plan were to conduct increased supervisory observation rounds of the residents to an hourly rate and to identify the high risk residents to have increase monitoring onto a (Outside) watch list. The facility's Immediate Plan of Correction stated: 7. We have increased rounds by safety personnel to the interior patios and exterior grounds of this building to hourly. 8. We have compiled an outside watch list (attachment: g) of residents that go outside and Instructed CNA's responsible for oversight of the resident to condict (sic) more frequent verification of their whereabouts. Nurse managers will follow-up as a second check for the identified residents. All staff have been instructed to be extra vigilant during extreme heat to monitor residents. A policy was also submitted with the self report, which included: The facility's Policy #: DRAFT effective 7/16/13 - SUBJECT: Excessive Heat Precautions POLICY: To protect our Residents during periods of excessive heat. PROCEDURE: 1. Cove Patio Doors a. The Cove patio doors will be locked once the outside temperature exceeds 90 degrees. b. No residents will be permitted to go outdoors during this time without direct supervision at all times. c. Once temperatures drop below 90 degrees the charge nurse or nurse manager will assess the safety of residents returning to the patio. 2. Patio gates will be locked on all neighborhoods when temperatures exceed 90 degrees. a. For resident safety, resident wanting to go outside may use the main front entrance to enter and exit the facility; his (sic) will allow staff to better track residents exiting the facility and track how long residents spend in the heat. a. A staff member will be assigned to monitor the main entrance during the periods of excessive heat to better track residents for safety purposes. Interviews: On 8/8/12 at 2:45 PM, the Performance Improvement Nurse indicated there were no policies related to heat warnings prior to the incident. The nurses used their judgement. The nurses closed doors when temperatures were high outside. The RN indicated, she noticed and heard nurses on the Cove talk to residents about the extreme weather and the need to close the doors to the outside. During an interview, the CNA on the Sidewinder unit revealed there was no official list of residents on a (Outside) Watch List. She further explained that CNAs on the Sidewinder unit are responsible for their assigned residents and watch over the other residents on the unit as needed. On 8/9/13 at 1:45 PM, the unit secretary from the Sidewinder unit was interviewed. The secretary was asked about the Outside Watch List. She printed a list of residents from all units of the building (Sidewinder, Mariner, Cove, and Falconer) and that the list identified residents who were on a Wander List. She was unfamiliar with, and was not able to provide, the Outside Watch List. Review of the list of residents on the Outside Watch List provided by Administration, which included: 4 residents from the Mariner unit; 11 residents from the Sidewinder unit and 2 residents from the Falconer unit. On 8/9/13, a random review of the CNA communication assignment sheets on the Sidewinder and the Falconer units did not identify for the CNA who was on the Outside Watch List. (Note: The facility was observed conducting increased rounds by the safety personnel to the interior patios and exterior patios of the building hourly.) Summary: The above observations, interviews and review of the documentation revealed that the summation of the staff's efforts was inadequate in providing preventive and protective supervision for Resident #4 from being over exposed to the sun/heat. Also, the facility's proposed corrective actions were not sufficiently implemented to prevent possible injury to all residents (the facility only identified high risk residents for protection and the basis for their selection was not clearly defined).