Every finding on record at North las Vegas Care Center

Based on observations, interviews, record review and document review, the facility failed to ensure residents were not confined to a room and barricaded bed, for 2 of 6 sampled residents (Resident 2 and 3). The deficient practice resulted in residents being confined to bed without consent, placing the residents at risk of psychosocial harm, loss of dignity, and compromised resident rights.Findings include:Resident 2 (R2) was admitted on [DATE] and readmitted on [DATE] with diagnoses including bipolar disorder and history of falling.Resident 3 (R3) was admitted on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, intellectual disabilities, and contractures.A review of facility reports revealed on 12/13/2025 at 4:00 AM, the Activities Director entered the building as the manager on duty and during initial rounds noted two residents were barricaded in bed. The report documented the residents had permission to have beds against the wall with one side open. The side of the bed which was supposed to remain open was blocked by a mattress held up by Geri chair locked in place.On 01/07/2026 at 11:00 AM, the Activities Director indicated entering the building through a side entrance. The Activities Director was conducting an observation of hallways and noticed a mattress against beds with a Geri-chair holding it in place. The Activities found the nurse assigned to the hallways in question. The nurse was questioned about mattress and indicated it was done for safety. After discussing with nurse, the Director of Nursing was notified. On 01/07/2026 at 10:00 AM, R2 indicated remembering the incident and at the time felt it was not appropriate to be confined to bed. R2 verbalized feeling safe in the facility now and was happy with the outcome of investigation and the steps the facility took.On 01/07/2026 at 10:35 AM, a Certified Nursing Assistant (CNA) verbalized understanding of the facility's protocol for allegations of abuse. The CNA explained the immediate supervisor and abuse coordinator would have been notified of the allegations. The CNA recalled having several in-service training courses throughout the year including abuse training within two days of incident involving involuntary seclusion of the two residents. The CNA confirmed part of the training included education on ensuring if there was a concern staff had with the care of residents it is brought to the attention of leadership.On 01/07/2026 at 10:40 AM, a Licensed Practical Nurse who served as the facility's Education Director verbalized being familiar with the incident regarding the involuntary seclusion of the two residents. The Education Director explained during the investigation there was a training plan developed which included the normal yearly abuse training and added elements found during the investigation thought to be helpful including training on staff reporting any out of the ordinary events or concerns. The Education Director referred to the additional training as if you see something, say something.On 01/07/2026 at 10:45 AM, a Unit Manager indicated being familiar with the incident and verbalized all staff training took place beginning 12/15/2025 approximately two days after the incident occurred. The Unit Manager confirmed part of the training included ensuring staff members notified leadership if any concerns were identified.On 01/07/2026 in the morning, the Director of Nursing (DON) indicated all three identified staff members were suspended pending investigation. The DON verbalized both residents were negative for any signs of abuse during the assessment. The investigation found residents were deliberately barricaded in bed. When staff were questioned, the staff stated, it was for safety. Two staff members who had knowledge of the seclusion and participated were terminated; the third staff member was given a written warning. Inservice was completed on 12/15/2025. The staff were reported to the Board of Nursing. The facility policy titled Abuse, Neglect, Exploitation, or Mistreatment, revised 10/23/2019, documented the facility leadership prohibited neglect, mental, physical and or verbal abuse, use of physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment and misappropriation of resident property. The facility maintained all allegations of abuse, neglect, and misappropriation of property were thoroughly investigated and appropriate actions taken. Investigations included but were not limited to the identification and removal of alleged perpetrator, identification of alleged victim, type of allegation, where and when the incident occurred, written summaries of interviews, a resolution, measures taken to prevent future incidents. The facility was confirmed to be in substantial compliance as of 12/18/25, after staff member interviews confirmed education on abuse and abuse reporting, termination of both the Licensed Practical Nurse and the CNAs employment, review of the in-service training completed on 12/15/2025, and review of documentation confirming the facility report to the State Board of Nursing.

Based on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was developed for use of an abdominal binder for a resident who had a history of gastrostomy tube (G-tube) dislodgement for 1 of 40 sampled residents (Resident 12). The deficient practice had the potential to place the resident at risk for G-tube dislodgement.Findings include:The Person-centered Care Plan policy revised 05/05/2023, documented a baseline care plan would be developed and implemented within 48 hours of admission and would include information necessary to properly care for the resident. R12 was admitted on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy, unspecified dementia and gastrostomy (G-tube) status.On 08/26/2025 at 10:07 AM, R12 laid in bed with eyes opened and appeared to be non- verbal. A tube feeding (TF) pump was off, a bottle of Jevity 1.2 and a water bag dated 08/25/2025 were hanging on the TF pump. R12's right hand appeared contracted while R12's left hand was holding and was pulling nasal cannula from nose. Two abdominal binders, one white and the other gray colored were observed on a table at the corner of R12's room.On 08/26/2025 at 10:11 AM, the Certified Nursing Assistant (CNA) assigned to R12 confirmed there were two abdominal binders in the resident's room. The CNA verbalized, not knowing what the orders were for the abdominal binder and deferred to the nurse.On 08/27/2025 at 8:45 AM, the Licensed Practical Nurse (LPN) assigned to R12 entered confirmed there were two abdominal binders inside the resident's room. The LPN was not certain on the instructions related to the abdominal binders. The LPN reported R12 had just returned from the hospital from a dislodged G-tube. After administering R12's medication through the G-tube, the LPN left the room without putting on R12's abdominal binder. A Nursing Note dated 08/19/2025, documented R12 was transferred to the hospital for G-tube replacement. The Hospital History and Physical dated 08/19/2025, revealed R12 was admitted to the hospital and underwent a percutaneous endoscopy tube (PEG tube) replacement.A Nursing Note dated 08/24/2025, revealed R12 returned from hospital with abdominal binder. The medical record lacked documented evidence that the resident's use of the abdominal binder was included in R12's baseline care plan. On 08/28/2025 at 3:17 PM, the Unit Manager recounted receiving report from a nurse on 08/19/2025 regarding R12 pulling out G-tube and the nurse was going to call the provider for a hospital transfer. On 08/28/2025 at 3:11 PM, the Director of Nursing (DON) recounted R12 was sent to hospital on the evening of 08/19/2025 due to G-tube dislodgement. The DON indicated expecting the admitting nurse to notify the physician of resident's readmission with an abdominal binder and obtain orders for the wearing schedule of the binder. The DON confirmed the medical record revealed the admitting nurse did not include use of the abdominal binder in the resident's baseline care plan and did not obtain a clarification order for the resident's abdominal binder. On 08/28/2025 at 3:23 PM, the DON indicated abdominal binders required a physician's order and one should have been obtained on readmission. If the admitting nurse missed this, subsequent nurses who observed the binder in the resident's room could have sought clarification on the binder. The DON indicated the resident just returned from hospital after pulling out G-tube which made it important for the binder to be in use. The DON indicated non-use of the binder placed the resident at risk for another G-tube dislodgement. The Staff Education Nursing Policy and Procedure 9th edition 2023, documented an abdominal binder required a physician's order and instructions to place binder from waist to the pubic line, check the binder placement at least once per shift and document accordingly. The [NAME] 9th edition, documented to consider placing an abdominal binder around a confused patient's abdomen to prevent the patient from pulling the tube.

Based on observation, interview, and document review the facility failed to ensure foods were stored per recommended standards and ice machines were cleaned in 3 of 4 ice makers in the facility. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness. Findings include:On 08/26/2025 in the morning, a tour of the kitchen was completed with the Dietary Director. There was an open jug containing lime juice in the walk-in cooler with an expiration date of August 25, 2025. There was an unlabeled and undated food item wrapped in aluminum foil stored in the reach in freezer.The Dietary Director explained the lime juice should have been discarded after the expiration date. The item wrapped in aluminum foil was a frozen burrito and should have been labeled and dated.On 08/27/2025 in the morning, a follow-up tour of the kitchen was completed with the Dietary Director. A carton of thickened lemon-flavored water was found stored in the reach in refrigerator that was opened on 08/22/2025 but had expired on 05/09/2025. A carton of thickened orange juice from concentrate was found stored in the reach in refrigerator that was opened on 04/19/2025 but had expired on 02/13/2025.The Dietary Director explained the thickened lemon-flavored water just came in on the last shipment. The Dietary Director stated staff should have checked the dates prior to stocking the items. The Dietary Director affirmed staff should have checked the dates on the carton of thickened orange juice and it should have been discarded after the expiration date. On 08/26/2025 in the morning, a walk-through of the main dining room and nursing unit nourishment rooms was completed with the Dietary Director. There was an ice machine in the main dining room with a whitish/brownish debris buildup on the inside of the ice machine lid connection and debris buildup of the side grill covering the filter of the ice machine. There was an ice machine in the 200-hall nourishment room with debris built up on the grill covering the filter of the ice machine. There was an ice machine in the 300-hall nourishment room with debris buildup on the grill covering the filter of the ice machine. There was a covered pitcher of dark yellow fluid in the refrigerator that was not labeled and dated. There was an ice machine in the 100-hall nourishment room with debris buildup on the grill covering the filter of the ice machine.The Dietary Director explained the ice machines were cleaned regularly and were recently cleaned. The Dietary Director affirmed the juice pitcher should have been both labelled and dated by facility staff.A facility policy titled Equipment and Utilities Management Program: Ice Machine revised 07/26/2017 revealed the frequency the ice machines should be maintained was quarterly- per the calendar. The procedures include observing the unit for proper functioning, cleaning debris from the control panel area, turn off unit and remove ice from bin, clean bin, replace ice and turn unit on. There were no other instructions as to cleaning the rest of the ice machine parts or areas in the procedures.A facility policy titled Food Safety in Receiving and Storage revised 06/20/2023 revealed food will be inspected for expiration dates and use by dates to ensure the dates were within acceptable parameters when the food is delivered to the facility and prior to storage.A facility policy titled Safe Food Handling revised 06/20/2023 revealed foods removed from the original packaging were stored in closed containers or tightly wrapped packages and labeled with the common name of the item and the date it was opened.

Based on observation, interview, and document review, the facility failed to maintain the laundry environment in a sanitary condition by allowing a non-operational dryer located in the clean area of the laundry to accumulate dust inside and on the exterior surfaces. The deficient practice had the potential to contaminate the clean linens and increase the risk of infection for residents.Findings include:On 08/29/2025 at 10:38 AM, the clean area of the laundry room revealed a bank of four commercial dryers. One dryer was non-operational and had visible dust and lint accumulated inside the drum, on exterior surfaces, and in the gap between machines. The dryer was in the clean area of the laundry where clean linens and clothes were processed and stored. On 08/29/2025 at 10:38 AM, the Director of Maintenance described the dryer as moderately dirty with lint and dust build up on inside and outside of machine.On 08/29/2025 at 10:40 AM, the laundry aide indicated the dryer had been broken for at least three years since the laundry aide began working at facility. The laundry aide verbalized it was the responsibility of the laundry staff to wipe down the front of the machine and maintenance would take care of the sides and back of the machine. On 08/29/2025 at 10:39 AM, the Director of Maintenance indicated a broken dryer had been there since starting employment 5 years ago. Last year, the Director of Maintenance contacted a facility consultant and was told to leave the dryer in place, the dryer would not be fixed nor replaced. No further instructions were given to the Director of Maintenance. On 08/29/2025 at 11:00 AM, the Infection Preventionist confirmed the buildup of dust or lint on the exterior of the machine and indicated it was a potential infection control concern with having the clean linens and clothes in the same area.On 08/29/2025 at 1:38 PM, the District Manager explained staff were expected to clean the laundry area including the front of the dryer and underneath. The district manager verbalized maintenance was responsible for cleaning the sides and back of the machines. On 08/29/2025 at 1:45 PM, the Administrator indicated there were several factors involved in making determination of whether to replace or remove large appliances and the facility was able to maintain washing and drying with the current three working dryers.On 08/29/2025 at 1:50 PM, the Director of Maintenance indicated the maintenance of the dryers including ensuring there was no dust, dirt, and lint build up on the exterior of the machine including in between the gaps and the back of the machine.The facility policy for laundry cleaning and maintenance was requested on 08/29/2025 and was not received prior to leaving the facility.

Based on interview and document review, the facility failed to ensure the facility had a Quality Assurance Performance Improvement (QAPI) plan. This deficient practice had the potential to negatively affect the outcomes of resident care and the quality of each resident's life.Findings include:On 08/29/2025 at 12:02 PM, the Administrator was not able to locate the facility specific QAPI plan. The Administrator explained that the facility was using the QAPI policy until the plan could be found.A facility policy titled, Quality Assurance and Performance Improvement Program Committee Guidelines, revised on 09/29/2021, did not identify the requirement of developing a facility specific QAPI Plan containing the processes that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. The QAPI Plan was used to guide the organizational and facility performance improvement efforts.

Based on observation, interview, record review and document review, the facility failed to ensure professional standards of practice were adhered to for timely administration of medications and correct medication preparation and administration technique for medications given via the enteral route for 3 of 40 sampled residents (Residents 10, 15, and 12). The deficient practice had the potential to place residents at risk for adverse effects related to medication errors.Findings include:1) Resident 15 (R15) was admitted on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction and gastrostomy status.On 08/27/2025 at 9:26 AM, a medication pass observation revealed R15's the following routine medications were administered to R15:- Aspirin 81 milligrams (mg) chewable- Gabapentin 100 mg- Metoprolol Tartrate 25 mg- Multi vitamin with IronReview of the medical record revealed R15's medications were scheduled to be administered at 8:00 AM.The Medication Administration Record (MAR) dated 08/27/2025, corroborated with the medication pass observation R15's medications were charted as being administered at 9:26 AM.2) Resident 10 (R10) was admitted on [DATE] and readmitted on [DATE], with diagnoses including cellulitis of left lower limb and quadriplegia.On 08/27/2025 at 10:02 AM, a medication pass observation revealed the following routine medications were administered to R10:- Acetaminophen 650 mg - Naproxen Sodium 220 mg- Allopurinol 300 mg- Vitamin C 500 mg- Vitamin B complex 100 mg- Vitamin B12 chewable 500 micrograms (mcg)- Baclofen 10 mg- Buspirone 30 mg - Calcium Carbonate Vitamin D3 10 mcg / (400 unit) - Cetirizine 10 mg - Ciprofloxacin 500 mg - Ferrous Sulfate 325 mg - Fish oil (Omega 3) 300 mg - Midodrine 5 mg - Multivitamin - Oxcarbazepine 150 mg - Zinc 50 mg Review of the medical record revealed R10's medications were scheduled to be administered at 8:00 AM.The Medication Administration Record (MAR) dated 08/27/2025, corroborated with the medication pass observation R10's medications were charted as being administered at 10:02 AM.On 08/27/2025 in the morning, Licensed Practical Nurse (LPN)1 confirmed medications administered to R15 and R10 were scheduled to be administered at 8:00 AM but were administered beyond the one-hour allowable window and were therefore considered late administration. LPN1 explained being assigned to 28 residents and had to hang two enteral feedings, check blood sugars and obtain vital signs for 13 residents due to a Certified Nursing Assistant (CNA) not providing vital signs for assigned residents. LPN1 indicated there were still 23 residents who have not received their morning medications. LPN1 indicated 28 residents was a normal work assignment for nurses and LPN1 expressed it was difficult if not impossible to administer medications timely for all assigned residents.On 08/27/2025 in the morning, LPN2 indicated being assigned 29 residents and this was the normal load for nurses at this facility. LPN2 indicated just completing medication pass for part of the 300-Hall and acknowledged medications for the last six residents were late. LPN2 indicated it was difficult to administer medications for 29 residents one hour before up to one hour after prescribed time.On 08/27/2025 at 10:25 AM, the 300-Hall Unit Manager explained there were two medication nurses assigned to the 300-Hall, and each were assigned 28 to 29 residents which was the normal workload for nurses at the facility. The Unit Manager explained that a CNA called off this morning and no coverage could be found so vital signs were not obtained for some of LPN1's residents. The Unit Manager indicated having worked the floor prior to becoming a Unit Manager and based on personal experience, the Unit Manager stated it was difficult if not impossible to administer medications for 28 or 29 residents in a timely manner due to other factors which could cause delays such as Gastrostomy tube (G-tube) feeding, transmission-based precautions (TBP) personal protective equipment (PPE) requirements, vital signs when CNAs call off and other unforeseen events. The Unit Manager explained CNAs were expected to obtain vital signs for all residents and provide the information to the medication nurses prior to medication pass.On 08/27/2025 at 10:31 AM, the Unit Manager indicated medications overdue for 23 residents by LPN1 and six residents by LPN 2 were a high number of late administrations which did not align with professional standards of practice and facility policy.On 08/27/2025 at 1:41 PM, the Director of Nursing (DON) indicated the professional standard of nursing practice adopted by the facility was [NAME]. The DON indicated scheduled medications were to be given one hour before or one hour after the prescribed time. The Lippincott Nursing Procedure (ninth edition) documented to promote a culture of safety and to prevent medication errors, nurses must adhere to the five rights which included right time. The Medication Management Program policy revised 01/15/2025, documented drugs must be administered at the right time and may be administered one hour before to one hour after the prescribed time.3) Resident 12 (R12) was admitted on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy, unspecified dementia and gastrostomy (G-tube) status.On 08/27/2025 at 8:45 AM, a Licensed Practical Nurse (LPN) was observed crushing multiple pills in a single pouch. The LPN entered R15's room with water and a piston syringe. 08/27/2025 at 8:50 AM, the LPN interrupted R15's enteral feeding to administer medications through the resident's G-tube. The LPN connected the piston syringe to R15's G-tube, poured water, added crushed medications and flushed with more water afterwards. The LPN resumed R15's enteral feed.On 08/27/2025 at 9:00 AM, the LPN indicated administering seven medications to R15 namely: 1) Vitamin C, 2) Ciprofloxacin, 3) Multivitamins, 4) Multivitamins with Iron, 5) Famotidine, 6) Losartan and 7) Memantine. The LPN acknowledged crushing the seven medications at once was not in accordance with facility policy. The LPN indicated each medication must be crushed in individual pouches, administered one at a time with water flushes in between. The LPN explained running behind with medication pass and crushed the medications together to save time. On 08/27/2025 at 10:21 AM, the Unit Manager indicated multiple medications should not be crushed at the same time for the following reasons: 1) some medications need to be verified if they could be crushed, 2) some medications may interact with the others causing adverse reactions 3) inaccurate documentation due to being unable to identify which medications were administered or not administered in the event of spillage or blockage. The correct method was to crush medications in individual pouches, flush with water before and after each medication to ensure and document accordingly.On 08/28/2025 3:06 PM the DON indicated the LPN who administered seven medications to R15 at once in the same pill pouch did not follow the [NAME] standard of nursing practice which the facility followed for enteral administration. The LPN should have crushed each medication individually in separate pouches and administered the medications one at a time with water flushes in between. The DON indicated the LPN did not follow correct medication preparation and administration procedure for enteral administration and placed R15 at risk for complications such as an occluded tube and drug-to-drug interactions. The Lippincott Nursing Procedure (ninth edition) documented a nursing alert: do not mix different medications intended for administration through enteral tube together because of the risks of physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses. The risk of complications increased with inappropriate preparation and administration technique.

Based on observation, interview, record review and document review, the facility failed to ensure a dependent resident was provided with nail care and hygiene to contracted hand for 1 of 40 sampled residents (Resident 12). The deficient practice had the potential to negatively impact residents' overall wellbeing.Findings include:The Activities of Daily Living (ADL) Optimal Function policy revised 05/05/2023, documented that the facility shall provide necessary care to all residents who were unable to carry out activities of daily living on their own to ensure proper nutrition, grooming and hygiene. Resident 12 (R12) was admitted on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy, unspecified dementia and gastrostomy (G-tube) status.On 08/26/2025 at 10:07 AM, R12's right and left hand had long fingernails, approximately one-fourth inch past the nail bed. R12's right hand was severely contracted while left hand had brown matter build-up underneath nails. The Quarterly Minimum Data Set (MDS) dated [DATE], revealed R12 had severely impaired cognition, and was dependent on staff for hygiene. On 08/26/2025 at 10:07 AM, the Wound Care Nurse confirmed R12's fingernails were long on both hands, and dirt build up was evident underneath the left hand. On 08/26/2025 at 10:11 AM, the Certified Nursing Assistant (CNA)1 assigned to R12 indicated not being familiar with R12 because CNA1 was newly hired. CNA1 described R12's fingernails on left hand as long and dirty and right fingernails were long and hand was severely contracted. CNA1 confirmed there was a splint on the bedside table and was not aware whether the splint was for R12's right or left hand or what the wearing schedule was. CNA1 indicated being able to trim and clean R12's nails since the resident was not a diabetic.On 08/27/2025 at 10:51 AM, an Occupational Therapist (OT) entered R12's room and explained the white splint was a palm guard which was meant for R12's contracted right hand. The OT indicated restorative nurse aides (RNAs) were expected to ensure the palm guard was in R12's right hand as part of contracture management. The OT explained the procedure should start with making sure R12's right hand was clean. The OT tried to open up R12's right hand with gloved hand, a brown-colored sweat was observed on the OT's blue gloves and foul odor became evident.On 08/27/2025 at 11:07 AM, the OT got a wet white cloth and cleanser and started cleaning R12's right hand. The OT described the hand as dirty with dead skin and moisture and had a foul odor. The OT described both hands as having a nail length of 1/4 inch over nail bed with heavy dirt build-up underneath nails on left hand. The OT indicated the amount of dirt inside R12's right hand and left fingernails could not have accumulated overnight which was evidence CNAs do not routinely assist R12 with nail care and hand hygiene.On 08/27/2025 at 11:08 AM, the Unit Manager confirmed R12's nails were long on both hands and had dirt built-up underneath left fingernails. The Unit Manager indicated expecting assigned CNAs to perform hand cleaning and nail trimming to R12.On 08/27/2025 at 11:18 AM, the Unit Manager described R12 as non-verbal and dependent on staff for all activities of daily living (ADLs) and hand and nail care should be provided once every shift and as needed. The Unit Manager indicated CNAs should not wait for RNAs to come to clean R12's right contracted hand and could have provided nail care for the resident.On 08/29/2025 at 8:19 AM, CNA2 indicated being familiar with R12 but this was the first time CNA2 had been assigned to R12 since the resident's return from the hospital. CNA2 indicated R12 was dependent on staff for all care. CNA2 recounted having provided care to R12's contracted right hand in the past and trimming R12's nails but could not speak to why other CNAs have not done the same.The Nursing Staff Education Policy & Procedure revised 01/12/2024, provided nurses with a step-by-step procedure to perform nail care which included soaking nails in water, grooming nails with scissors or clippers, smoothening out rough edges, cleaning under nails with orange stick. The Care for Contracture hands policy revised 05/05/2025, documented steps to perform hand hygiene on contracted hands which included soaking the resident's hand in soapy water for 15 minutes, rinse thoroughly and place hand roll in the palm of the hand.

Based on observation, interview, record review and document review, the facility failed to ensure therapy recommendations for use of a palm guard for a resident with severe hand contracture were transcribed as an order and implemented for 1 of 40 sampled residents (Resident 12). The deficient practice had the potential to place the resident at risk for worsening contracture and pain.Findings include:R12 was admitted on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy, unspecified dementia and gastrostomy (G-tube) status.On 08/26/2025 at 10:07 AM, R12's right hand was severely contracted. A white hand splint was observed on the bedside table.On 08/26/2025 at 10:11 AM, the Certified Nursing Assistant (CNA) assigned to R12 indicated not being familiar with R12. The CNA confirmed R12's right hand was severely contracted and there was a white splint device on the bedside table, but the CNA indicated not being familiar with the splint device's wearing schedule.On 08/27/2025 at 8:45 AM, a Licensed Practical Nurse (LPN) confirmed the white hand splint was on the table and not worn by R12. The LPN indicated not being familiar with the splint's wearing schedule and deferred to the restorative nurse aide (RNA).On 08/27/2025 at 10:51 AM, an Occupational Therapist (OT) explained the white splint was a palm guard which was meant for R12's contracted right hand. The OT indicated restorative nurse aides (RNAs) were expected to ensure the palm guard was in R12's right hand as part of contracture management.On 08/27/2025 at 11:09 AM, the Case Manager indicated leading the RNA team who consisted of two RNAs on the floor each day. The Case Manager indicated R12 was not currently on the RNA case load.An OT Discharge summary dated [DATE], documented R12 on splint and brace program and would benefit from RNA services. RNA to put on and take off the right palm guard for six hours and as tolerated.On 08/28/2025 at 3:27 PM, the Director of Nursing (DON) explained R12 was admitted with a severely contracted right hand on 01/14/2025 and the OT evaluation dated 01/15/2025, documented a recommendation for right palm guard. Therapy recommendations would be sent to the RNA team who would conduct an observation and if RNA agreed with therapy recommendations the RNA would write a nursing order. The DON indicated R12 was discharged from therapy on 01/28/2025 with a recommendation for additional attention to R12's right hand, restorative splint and brace program, RNA to to put on and take off the right-hand palm guard six hours as tolerated. On 08/28/2025 at 3:40 PM, the DON stated the OT recommendation should have been converted into a nursing order, but this was not done. The DON indicated nursing staff who were entering R12's room should have obtained clarification on the use of R12's palm guard. The DON verbalized non-use of the palm guard placed R12 at risk for nail injury, infection and pain. The Restorative Nursing Policies and Procedures revised 10/25/2024, documented the facility was committed to providing quality care and services to all residents and the restorative nursing program was an integral component of nursing practice which contributed to achieving this goal. The restorative program aimed to promote an enhanced quality of life. Upon admission, each resident would be assessed for interventions needed to correct, improve or maintain health status. Interventions would be communicated to the resident and appropriate parties.

Based on interview and record review, the facility failed to ensure the facility assessment policy was reviewed and updated to reflect new guidance which included the active involvement of direct care staff, input from residents, resident representatives, family members and ensuring there were sufficient number of competent staff to meet the needs of each resident and failed to involve direct care staff in the development of the facility assessment. The deficient practice had the potential to result in an incomplete evaluation of resident population and facility resources, which could affect staffing decisions, training, and availability of services needed to meet resident needs. Findings include: A review of the facility assessment policy dated 2017 revealed the policy had not been updated to include new Centers for Medicare and Medicaid (CMS) guidance which included: active involvement of direct care staff and input from residents, resident representatives and family members in developing the facility assessment. The facility assessment tool did not include documentation to show input from direct care staff such as certified nursing assistants and floor nurses, in the development process.On 08/28/2025 at 11:57 AM, the Administrator indicated the facility assessment was completed at least annually or when there were significant changes to building. The Administrator explained direct care staff was involved in the input during Quality Assurance and Performance Improvement (QAPI) meetings for facility assessment. The Administrator could not provide documented evidence of how the direct care staff was involved in determining the staffing plan for the facility. On 08/29/2025 at 1:52 PM, the Administrator and Director of Nursing confirmed the facility assessment policy has not been updated since 2017. The Administrator and Director of Nursing acknowledged being aware of the guidance issued by CMS in 2024 however policy was not updated to include the new guidance.The facility policy titled Leadership Framework Administration Policy (revised November 2017) documented that the facility must conduct and document a facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies.

Based on observation, interview, record review, and document review, the facility failed to ensure the comprehensive care plan was revised to include identification of the need for oxygen therapy and corresponding interventions for 1 of 40 sampled residents (Resident 41). The deficient practice had the potential to result in unmet respiratory care needs, lack of staff guidance, and inadequate monitoring of oxygen therapy, which could compromise the resident's respiratory status. Findings include:Resident 41 (R41) was admitted on [DATE] with diagnoses including pulmonary hypertension and acute chronic systolic heart failure.A Physician Order dated 05/24/2025 and updated on 06/17/2025 directed oxygen at 2 liters per minute via nasal cannula, with monitoring of oxygen saturation every shift and oxygen tubing and humidification systems be changed weekly.On 08/26/2025 at 12:11 PM, R41 was receiving oxygen at 2.5 liters per minute via nasal cannula. The oxygen tubing was in use and not labeled or dated.The Medication and Treatment Administration Record revealed documentation R41's oxygen tubing was changed weekly as ordered.A Progress Note dated 05/24/2025 acknowledged the physician order for oxygen.The comprehensive care plan did not identify the use of oxygen or include interventions for management of oxygen therapy needs.On 08/27/2025 at 12:15 PM, a Registered Nurse (RN) confirmed any resident on continuous oxygen therapy would have oxygen therapy included in the care plan.On 08/28/2025 at 2:33 PM, the Unit Manager confirmed the care plan had not been revised to include oxygen therapy. The Unit Manager indicated the oxygen care plan usually was only indicated when there was a concern or compliance issue with the resident. The Unit Manager acknowledged any nursing staff would be able to update the care plan and should have been revised to include new or changed orders.On 08/29/2025 at 1:30 PM, the Director of Nursing (DON) indicated any resident receiving oxygen should have it included in the comprehensive care plan and confirmed R41 did not have a revised care plan to include the oxygen therapy which was initiated after the initial comprehensive care plan was completed.The facility policy titled Care Plan Process, Person-Centered Care (revised May 3, 2023) documented the facility would develop and implement a baseline and comprehensive care plan for each resident and include instructions needed to provide effective and person-centered care. Through ongoing assessment, the facility would initiate person-centered care plans when the resident's clinical status or change of condition dictates the need.

Based on interview, record review and document review, the facility failed to ensure a resident was kept safe from abuse for 1 of 40 sampled residents (Resident 166). The deficient practice had the potential for residents to experience emotional distress and physical harm.Findings include:Resident 166 (R166) was admitted to the facility on [DATE] with diagnoses including fusion of cervical spine, cocaine abuse with cocaine-induced psychotic disorder with hallucinations, depression, and pain.The Administrator was notified on 04/15/2025 of an allegation of abuse which occurred on 04/12/2025. R166 reported that a certified nursing assistant (CNA) was rough when changing the resident's brief. The resident reported the CNA tugged on the resident. The CNA was removed from the resident's care for the remainder of the shift due to the resident and CNA not getting along. When the facility was notified of the allegation of abuse the employee had resigned from the facility. An investigation was conducted, and the facility substantiated the allegation of abuse. The Director of Social Services met with R166 who indicated feeling safe in the facility and did not experience any negative impacts from the incident. A psychosocial well-being care plan was initiated to monitor the resident for any negative outcomes related to the incident. The CNA was reported to the nursing board. Abuse and neglect training for staff was conducted on 04/17/2025.The facility policy titled Abuse, Neglect, Exploitation, or Mistreatment, documented the facility's leadership prohibited neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of residence property, are reported and investigated immediately.During the onsite investigation from 08/26/2025 through 08/29/2025, the facility was found to be in compliance regarding abuse regulations as evidenced by observations of staff and resident interactions were respectful and courteous and interviews with residents revealed no concerns with how staff treated the residents. Facility Reported Incident 2287896

Based on observation, interview, record review and document review, the facility failed to ensure medications were secured and not left at residents' bedside for 2 of 40 sampled residents (Residents 14 and 15). The deficient practice had the potential to place the residents at risk for adverse reactions to potential medication errors.Findings include:1) Resident 14 (R14) was admitted on [DATE] and readmitted on [DATE], with diagnoses including osteomyelitis of the vertebra and sacral region and Vitamin deficiency.On 8/26/2025 at 8:48 AM, R14 laid awake and alert in bed. A medication cup with two white pills and a red capsule was observed on the bedside table. R14 indicated not being certain what the pills were and could not explain why and who left the medications on the table.On 08/26/2025 at 8:51 AM, Licensed Practical Nurse (LPN)3 confirmed there was a medication cup with two white pills and a red capsule on R14's bedside table. LPN3 reviewed R14's medications in the medication cart and identified the white pills as Vitamin C and the red capsule as Ferrous sulfate. LPN3 indicated the night nurse must have left the medications because LPN3 had not gone into R14's room since start of shift. LPN3 indicated medications were not to be left at bedside and must be consumed or refused in the presence of the nurse. LPN3 indicated R14 did not have a self-administration assessment to take own medications. The nurse would have to directly observe the medications consumption before documenting the medication as administered. 2) Resident 15 (R15) was admitted on [DATE] and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction and gastrostomy status.On 08/27/2025 at 9:24 AM, an unlabeled medication cup with white powder was observed on R15's bedside table. LPN1 confirmed the observation and indicated the medication appeared to be Nystatin powder which was supposed to be used for R15's body rashes. LPN1 indicated the medication should not have been left at bedside by the pervious shift.On 08/27/2025 in the afternoon, the Unit Manager verbalized medications must not be left at the resident's bedside for safety reasons. The nurses who left medications on the bedside tables of R14 and R15 did not follow the facility's policy to secure medications.On 08/29/2025 at 8:56 AM, the Director of Nursing (DON) indicated medications must be kept in the presence of authorized staff and not left at the bedside. The facility had a process for residents who expressed the desire to self-administer own medications but currently the facility had no residents who requested to self-administer medications. The DON indicated the night nurses who left the medications at the bedside table of Residents 14 and 15 did not follow the facility policy for medication storage and medication administration. The DON stated it did not matter whether the medications were high risk or not, but rather the issue was unsecure medications placed residents at risk for potential drug adverse effects. The Medication Management Program policy revised 01/15/2025, documented medications were dispensed at the time of administration. Pre-pouring or dispensing for a later administration is not permitted. The licensed nurse must remain with the resident while the medication was swallowed. Never leave medication in a resident room without an order to do so.

Based on observation, interview, and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which were significant to the residents for 1 of 40 sampled residents (Resident 46) and 6 unsampled residents from the resident council interview. The deficient practice had the potential for the facility to not accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents.Findings include:The facility had a large patio which was surrounded, in total, by different hallways of the building. The patio contained a large gazebo type structure that was fitted with ceiling fans and a misting type of system. The gazebo contained flower boxes some of the residents used to grow and take care of flowers and other plants. There was a note taped to the doors used to enter/exit this outside area which read: Center Courtyard, Mon-Sun Open: 7:30 AM Close: 5:00PM.Resident 46 (R46) was re-admitted to the facility on [DATE] with diagnosis of generalized abdominal pain and other secondary thrombocytopenia. R46 had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact normal cognition. On 08/26/2025 in the afternoon, R46 revealed they would like to be able to go outside and sit under the gazebo in the evening as it was cooler, but the facility would not let us and locked the doors. R46 expressed it was too hot during the day to go sit outside, but when it started to cool down outside, around 6:00 PM, the patio area was already closed.During the Resident Council Meeting on 08/27/2025 at 11:00 AM, six residents reported residents were not permitted to go outside into the courtyard of the building past 5:00 PM. Maintenance Staff locked the doors at 5:00 PM. The residents indicated it did not start to cool down until around 6PM and by that time the courtyard was already locked. The issue had been brought up a few times by the resident council and the facility had not provided a rationale for the courtyard doors being locked at 5:00 PM. The residents were told locking the doors was due to the heat however, this did not make sense as the heat was easing by 6:00 PM and the gazebo had fans and misters as well as the staff left a water cooler there for the residents to get water.On 08/27/2025 at 12:35 PM, the Activity Director (AD) confirmed the gazebo area outside was open from 7:30 AM to 5:00 PM. The AD explained Maintenance staff locked the doors at 5:00 PM. The AD indicated there was not enough staff supervision to make sure there was enough water available for the residents to drink after 5:00 PM and it was not too hot for the residents. The AD acknowledged the residents in resident council have voiced their issues with this rule in at least two resident council meetings. The AD acknowledged hearing residents talking about it in the dining room and during group activities in the activity room.On 08/27/2025 at 1:14 PM, the Administrator stated the reason for the locked doors to the courtyard was because of the high temperatures in the city and not necessarily due to the availability of supervision of the residents. The administrator explained the facility just wanted to protect the residents. The Administrator acknowledged the weather was starting to cool around 8 PM so there was no reason why the doors had to be locked since there were lights, fans, and misters in the covered patio area.The facility's Resident Rights policy revealed the resident had a right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to residents' choice of activities, schedules, healthcare and providers of healthcare services consistent with the resident's interests, assessments and plans of care. The residents had the right to make choices about aspects of their life in the facility that were significant to the residents.

Based on observation, record review and interview, the facility failed to provide pain medication as requested, assess, and document resident pain level accurately according to physician's order for 1 of 1 unsampled residents (Resident 4). The deficient practice placed the resident at risk for ineffective and inadequate pain control. Findings include: Resident 4 (R4) was admitted on [DATE] with diagnoses including angina pectoris, muscle wasting and atrophy, chest pain, absences of right and left leg below the knee, and pain. On 01/30/2025 at 10:23 AM, a Licensed Practical Nurse (LPN3) verbalized if medication is not available for a resident, a nurse should check the Omnicell (onsite medication dispensing machine) for the medication before waiting for the pharmacy to deliver the medication. On 01/30/2025 at 10:35 AM, the Registered Nurse Unit Manager (RN3) indicated the nurses use the Omnicell often to ensure resident do not go without medication. On 01/30/2025 at 10:42 AM, R4 was lying in bed, alert and oriented. R4 verbalized Norco (narcotic pain medication) not being given upon request during morning medication pass because the facility had run out of medication, and the resident would have to wait until the facility received the medication. R4 indicated only being given Tylenol but was still in pain. On 01/30/2025 at 10:48 AM, another LPN (LPN2) indicated if a resident does not have medication, the nurse can retrieve it from the Omnicell. On 01/30/2025 at 10:57 AM, LPN3 verbalized R4 had run out of Norco, but the pharmacy had indicated the medication would arrive around 11:30 AM. LPN3 indicated the resident had orders for Tylenol, and LPN3 had administered Tylenol while waiting for the Norco to arrive. LPN3 asked R4 if the resident was still in pain, and R4 confirmed the Tylenol was not effective and would like additional pain medication. LPN3 asked the resident if R4 would like additional Tylenol or Norco that can be pulled from the Omnicell. R4 verbalized wanting the Norco instead. The Omnicell inventory list indicated Hydrocodone-acetaminophen (Norco) - 5/325 mg was included in the inventory. R4's Comprehensive Care Plan dated 09/19/2024 documented the resident has pain and discomfort, and staff must assess and monitor for signs and symptoms of increased pain or discomfort. R4's medical record revealed Physician orders for: - Check resident for level of pain (8AM - 4PM - 8PM). Dated 08/31/2022 - Acetaminophen (Tylenol), over the counter - 325 milligrams (mg), administer 2 tablets (650 mg) as needed every 6 hours for moderate pain from 3-5. Dated 06/01/2023 - Hydrocodone-acetaminophen (Norco) - 5/325 mg, administer 1 tablet as needed every 4 hours for pain scale from 6-10. Dated 11/27/2023 R4's Medication Administration Review (MAR) for Acetaminophen lacked documented evidence of being administered on 01/30/2025. The MAR for Hydrocodone-acetaminophen documented being administered on 01/30/2025 at 11:16 AM. On 01/30/2025 at 11:49 AM, R4 indicated being at a pain level of 9 in the morning when the Tylenol was given, but the resident was feeling much better after receiving the Norco. On 01/30/2025 at 11:53 AM, LPN3 indicated not administering Tylenol and confirmed not administering any pain medication to the resident. LPN3 verbalized not asking the resident about the level of pain during the morning medication pass and incorrectly marking a pain level of 0 in the MAR. LPN3 conveyed if the resident's pain level had been properly monitored, the resident would have received pain medication sooner and not have been in pain. On 01/30/2025 at 11:30 AM, the Director of Nursing (DON) advised the pharmacy monitors and keeps the Omnicell stocked monthly. The DON verbalized the expectation for the nursing staff is to take medication from the Omnicell instead of waiting for the pharmacy to send it. The DON emphasized if a resident indicated a pain level of 8 to 10, the nursing staff should pull medication from the Omnicell, if the medication is available. The DON indicated LPN3 should have taken the Norco from the Omnicell instead of administering Tylenol. On 01/30/2025 at 2:27 PM, the DON verbalized if the resident's level of pain is not checked, it can delay the treatment and cause the pain to not be addressed. The DON indicated a pain level of 0 should not be given pain medication. The Medication Procurement policy revised 04/17/2024, documented the facility would utilize the onsite medication dispensing system when immediate medication administration is required. The Pain Management policy revised 05/05/2023, documented ongoing evaluation of resident's pain level will be used as the basis for revision of the comprehensive care plan. If the resident's pain is not adequately controlled, the resident's care plan may need to be revised.

Based on observation, interview, record review, and document review, the facility failed to ensure a medication was administered timely to 1 of 3 sampled residents (Resident #2). The deficient practice had a potential for the intended use of the medication to be insufficient or ineffective with a possible cause of harm to the resident. Findings include: Resident #2 (R2) R2 was originally admitted to the facility on [DATE] with diagnoses of Parkinson's Disease without dyskinesia, chest pain, personal history of transient ischemic attack, and cerebral infarction without residual deficits. A physician order dated 06/07/2024 for Doxycycline Hyclate 100 milligram (mg) tablet was ordered for cellulitis and was to be given at 9:00 AM and 9:00 PM. The medication administration record (MAR) revealed the resident missed the 9:00 PM dose on 06/07/2024, both doses on 06/08/2024, and the first dose of the medication was administered on 06/09/2024 at 9:00 AM. The MAR documented the facility was awaiting delivery of the medication from the Pharmacy. A physician order dated 06/07/2024 for Amoxicillin- Pot Clavulate 875-125 mg tablet was ordered for cellulitis and was to be given at 9:00 AM and 9:00 PM. The medication administration record (MAR) revealed the resident missed the 9:00 PM dose on 06/07/2024, both doses on 06/08/2024, and the first dose of the medication was administered on 06/09/2024 at 9:00 AM. The MAR documented the facility was awaiting delivery of the medication from the pharmacy. An Omnicell (an automated medication dispensing system which stores and tracks medications) medication availability log, revealed the Doxycycline Hyclate 100mg tablet and the Amoxicillin- Pot Clavulate 875-125 mg tablet were both available in the Omnicell at the facility to be used for the resident. On 01/30/2025 at 12:45 PM, a Licensed Practical Nurse (LPN) Unit Manager, confirmed the Omnicell medication availability log did contain the Doxycycline Hyclate 100mg tablet and the Amoxicillin- Pot Clavulate 875-125 mg tablet and both were available in the Omnicell at the facility to be used for the resident. On 01/30/2025 at 02:16 PM, the Director of Nursing (DON), confirmed it is the policy of the facility to use the Omnicell machine for unavailable medications. The DON stated there is someone in the facility at all times which has access to the Omnicell machine. The DON also verified the physician had not been notified of the late start date of either of the medications. A facility policy titled Medication Procurement: Emergency Boxes and On-Site Stores revised 04/17/2024, documented on-site stores of medications were to be utilized in the care of new admissions, new orders unable to be received before the next scheduled pharmacy delivery, or when immediate medication administration were required.

Based on observation, interviews, record review, and document review the facility failed to ensure care orders were entered and carried out for a colostomy (a surgical opening in the abdomen which provides a means for the collection of waste from the colon) in accordance with the resident care plan and facility policy for 1 of 32 sampled residents (Resident 69). The deficient practice had the potential for introducing infection and negative outcome of residents with a colostomy. Findings include: Resident 69 (R69) R69 was admitted on [DATE] and readmitted on [DATE]. On 09/09/2024 at 11:30 AM, R69 verbalized receiving care from the Certified Nursing Assistant (CNA) regarding colostomy however was not sure when the last time the barrier wafer was last changed on the colostomy. The medical record lacked documented evidence of any physician orders for the care and management of colostomy. On 09/10/2024 at 9:45 AM a CNA indicated the CNA would provide basic cleaning care for residents with a colostomy. The CNA would clean the area around the colostomy, ensure it was draining appropriately and change collection bag if needed. If the CNA noticed any concerns such as leaking or loose appliance, the nurse would be notified. Colostomy care would be documented in the electronic health record. The medical record revealed progress notes regarding colostomy were limited to identifying the colostomy was intact. The medical record did not indicate measures taken to monitor the colostomy or provide cleaning and care or changing the skin barrier wafer (appliance). On 09/10/2024 at 9:49 AM, a Licensed Practical Nurse indicated the CNA was responsible for cleaning around colostomy site, if the appliance on the colostomy needed to be changed the nurse would generally complete, however the CNA was trained to change appliance and bag. When a resident had colostomy there would be a physician order to identify the device used and frequency of cleaning and changes of appliance. The LPN indicated there were no orders for the resident of concern. On 09/10/2024 at 9:52 AM, the Unit Manager indicated there were no care and management orders for colostomy for resident of concern and there should be. When a resident had a colostomy, it would be identified during assessment and care and management orders should be entered. If there were no orders, there was a potential the needed care would be missed for the resident. On 09/11/2024 at 8:04 AM the Director of Nursing (DON) indicated when resident was admitted with colostomy a physician order should be obtained to clarify the type of care needed, how often and frequency of changing the colostomy appliance. The DON verbalized it was not appropriate to only document colostomy care in the care plan or physician orders. The facility policy titled Ostomy Care (revised 06/01/2015), documented ostomy appliances (wafers) usually stay on for five to seven days. If the resident experiences leakage, burning or pain underneath the appliance/wafer, it should be changed immediately and the peristomal skin evaluated.

Based on observation, interview, record review and document review, the facility failed to ensure 1) the physician was notified of a high Vancomycin trough level (laboratory monitoring of Vancomycin to maintain therapeutic blood levels and prevent serious side effects) prior to administration of next dose and, 2) there was a physician order to hold Vancomycin when the nurse decided to not administer the medication during subsequent shift for a resident who was being treated for bacterial pneumonia for 1 of 32 sampled residents (Resident 143). The deficient practice placed the resident at risk for ineffective antibiotic therapy and serious side effects. Findings include: Resident 143 (R143) R143 was admitted on [DATE] and readmitted on [DATE], with diagnoses including intracranial injury with loss of consciousness and bacterial pneumonia. A physician's order dated 09/08/2024, documented to give Vancomycin reconstituted solution 1,000 milligrams (mg) 1.25 grams, intravenously (IV) every eight hours at 8:00 AM, 4:00 PM and 12:00 AM for bacterial pneumonia. On 09/09/2024 at 9:02 AM, R143's eyes were opened, but the resident was non-verbal. An IV pole was observed on the right side of R143's bed and a bag of IV Vancomycin 1,000 mg was infusing at 167 milliliters (ml) per hour through R143's right upper arm midline (IV access). On 09/10/2024 at 8:05 AM, R143 laid in bed with eyes opened. R143's enteral feeding was infusing but the IV pump was not in use. On 09/10/2024 at 8:07 AM, the Licensed Practical Nurse (LPN) indicated R143's IV Vancomycin scheduled for 8:00 AM would be held due to the night nurse's verbal report from the night nurse. The LPN explained the night nurse verbalized being responsible for entering laboratory orders for a Vancomycin trough level and would take care of coordinating with the laboratory vendor but according to the LPN, the laboratory technician had not arrived. The medical record lacked documented evidence the night nurse communicated the pharmacy request for a Vancomycin trough level with the physician, obtained and entered orders for a Vancomycin trough level to be drawn and coordinated with the laboratory vendor regarding the pharmacy request. The Laboratory book dated 09/09/2024 documented the resident's Vancomycin trough level had already been drawn on 09/09/2024 at 3:30 PM, specifically, the specimen was obtained at 3:19 PM, received by laboratory at 4:47 PM, verified by lab at 4:57 PM and results received by the facility at 11:26 PM. The laboratory report dated 09/09/2024, revealed R143's Vancomycin trough level was 21.8 microgram per milliliter (ug/ml). Reference range: 10.0 to 20.0 ug/ml. Interpretation: High. The medication administration history report revealed the night nurse administered R143's Vancomycin's 12:00 AM dose on 09/10/2024. The medical record lacked documented evidence the nurse notified the physician regarding R143's high Vancomycin trough level which was made available to the facility at 11:26 PM on 09/09/2024. On 09/10/2024 at 9:10 AM, a Registered Nurse (RN) explained R143's Vancomycin trough had been drawn on 09/09/2024 at 3:30 PM and results were provided to the facility at 11:26 PM, more than 30 minutes prior to the next scheduled dose of 12:00 AM. The RN indicated the night nurse was an agency nurse who may not have been familiar with the laboratory book nor knew how to look up results in the electronic health record (EHR). On 09/10/2024 at 9:18 AM, the RN indicated the night nurse should have been aware of R143's high trough levels and communicated the abnormal result with the physician to enable the physician to provide guidance on whether to hold, delay or still administer the medication. On 09/10/2024 at 9:38 AM, the LPN acknowledged not personally verifying in the EHR on whether the night nurse had obtained orders for the resident's Vancomycin trough or whether a Vancomycin trough result was available in the EHR. The LPN confirmed there was no documentation nor information relayed by the night nurse that the physician was contacted for guidance and direction. The LPN acknowledged R143's scheduled 8:00 AM dose was held based solely on the verbal report from the agency night nurse. The LPN indicated the LPN should have verified Vancomycin trough levels in the EHR and contacted the physician before deciding to hold this morning's dose. On 09/10/2024 at 9:29 AM, the Unit Manager indicated the nurse who entered R143's Vancomycin orders on 09/08/2024 should have obtained and entered orders for laboratory monitoring for safety reasons since the medication was associated with certain toxicities. The Unit Manager confirmed R143's trough levels had been drawn and made available to the facility on [DATE] which the night nurse was expected to check prior to administering the midnight dose. In addition, the Unit Manager indicated the LPN should not have held R143's Vancomycin scheduled 8:00 AM dose without a physician's order. On 09/10/2024 at 1:36 PM, the Director of Nursing (DON) indicated Vancomycin was an antibiotic which had a narrow therapeutic index and came with blood monitoring requirements to attain therapeutic levels. According to the DON, when Vancomycin levels were low the drug would be ineffective and may cause toxicities when high. The DON indicated it was important for nursing to coordinate closely with pharmacy who was responsible for proper dosing and the physician who alone can order the drug to be held, delayed or given. The DON confirmed and emphasized the following: -the agency night nurse did not but should have known how to look up R143's Vancomycin trough levels which were made available to the facility on [DATE]. -the agency night nurse should have communicated R143's high trough levels with the physician prior to administering the medication on 09/10/2024 at 12:00 AM. - the LPN should not have held R143's 8:00 AM Vancomycin without a physician's order. The LPN did not administer the medication based solely on the verbal report from the night nurse, without verifying results were available in the EHR and without documentation the physician had not yet been notified. - the nurse who entered the Vancomycin orders should have sought clarification, obtained and entered orders for blood monitoring such as Vancomycin trough levels and frequency thereof. The Pharmacy vendor's Vancomycin guidelines (2024), documented to 1) ensure initial Vancomycin orders included laboratory monitoring of Vancomycin levels and serum creatinine, 2) administer doses on time to achieve sustained serum concentrations, prevent resistance and progression of infection and mortality, 3) dose changes would be based on laboratory results if ordered by the prescriber and 4) do not hold dose unless there was a prescriber order to hold and 5) report laboratory results promptly for review. The IV Vancomycin education document (undated) which was provided by the DON, documented Vancomycin was an effective antibiotic used to treat a wide variety of bacterial infections. Vancomycin had a narrow therapeutic index (easy to underdose and overdose). Blood work was recommended to ensure proper dosing and to prevent kidney and ear damage.

Based on observation, interview, record review, and document review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) Level 2 evaluation for newly found changes or diagnosis for 4 of 32 sampled residents (Resident 115, 81, 139 and 119). 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: Resident 115 (R115) R115 was admitted on [DATE], with an admitting diagnoses including chronic pancreatitis and blindness. On 08/09/2024 at 9:00 AM, the resident was observed lying in bed. During the introduction, R115 stated not wanting to talk to anyone and sternly ordered to leave the room. On 08/10/2024 and 08/11/2024 in the morning, R115 was observed wheeling self along the hallways while constantly talking to self. R115 was observed stopping at other resident room doorways and continuously talking even with no one inside the room. R115's Admission History and Physical dated 03/29/2024, lacked documented evidence under History of Present Illness (HPI) of any psychological symptoms suggesting a behavioral diagnosis. R115's listed Past Medical History: Blindness and history of polysubstance abuse. The facility provided R115 Admission PASRR dated 04/10/2023, documented Determination: No mental illness (MI), intellectual disability (IDD), and/or conditions related to intellectual disability (RC) or Dementia. Psychiatric Evaluation dated 03/30/2024 at 2:18 PM, documented Assessment: Patient had reported issues with anxiety over conditions, depression due to conditions, ongoing problems with pain and insomnia, suggest sleeping medications at bedtime, will discuss power of attorney (POA) with family, no capacity to leave against medical advice (AMA) and suggest discharge planning with social worker. Psychiatric Progress Notes dated 05/19/2024 at 3:43 PM, documented Assessment: Patient had reported issues with anxiety over conditions, depression due to conditions, ongoing problems with pain and insomnia, will adjust medications. Psychiatric Progress Notes dated 08/11/2024, documented Psychiatric Review of Systems: positive for anxiety and insomnia/sleep changes. Assessment: Patient had reported issues with anxiety over conditions, refused all options, stopped taking antidepressant, discussed options, declined different anti-depressant despite reports of previously taking the medication. The patient declines to take this medication and will not order additional medications. All psychiatry consults visits had documented the diagnoses of: Anxiety and major depressive disorder (MDD), recurrent - severe with psychotic symptoms. Review of R115's nursing progress notes from 08/01/2024 to current revealed the following behavioral incidences: - The resident requires frequent redirection, - The resident has outburst and makes repetitive delusional statements, - The resident is argumentative with staff and is disruptive to other residents due to yelling and going in their rooms. - The resident refuses psychotropic medications and sleep aides. - The resident continues to wheel self up and down the hallway, talking to self, shouting to others walking by, and lifting shirt up. - The resident has been confrontational with staff, being very loud, stating wanting to leave. - The resident has been hard to redirect. - The resident is insistent on leaving facility, packed bags and roaming through halls. A progress note entry dated 09/11/2024 at 1:33 PM, documented R115 was yelling at medical transport as the resident refuses to be taken to North Vista Hospital and the resident wants to go to University Medical Center (UMC). Informed medical transport know this was a L2k hold (Legal 2000 - a term used in Nevada for a mental health crisis hold) from resident's psychiatrist but medical transporters stated the resident can go where pleases as long as vital signs are stable and is alert and oriented. The nurse informed both primary and psychiatrist know regarding what medical transport had stated. Resident took all belongings and stated, I'm never coming back here. Transport documents, L2K forms, and physicians' orders. Social services and DON made aware; Unit Manager called Emergency Department at UMC to give report on resident at 1:30 PM. Resident 81 (R81) R81 was admitted on [DATE], with an admitting diagnoses including significant for diabetes and neurocognitive disorder. On 08/09/2024 at 9:40 AM, the resident was observed verbally abusive to plumbers fixing the resident's sink. R81 was constantly yelling in Spanish to the contractors and at times to no one. On 08/10/2024 and 08/11/2024 in the morning, R81 was observed pacing inside the room, talking to self. R81's re-admission History and Physical dated 04/24/2024, documented the patient was found wandering and having suicidal ideation. The patient was evaluated in the emergency department, medically cleared and admitted to hospital psychiatric unit for further evaluation and treatment. Once the patient's psychotropic intervention was optimized and patient's mental health stabilized, patient was discharged to skilled nursing facility for ongoing care and treatment. The facility provided R81's Admission PASRR dated 10/12/2023, documented Determination: Dementia Alzheimer OBS. Psychiatric Evaluation dated 12/24/2023, documented Assessment: History of schizoaffective disorder, recent hospitalization , refusing medications, ongoing issues with compliance, discontinued oral medications due to refusals and no criteria for forced medications. The patient was requesting to leave against medical advice (AMA), but no capacity and coordinate with family. Psychiatric Evaluation dated 08/16/2024, documented Assessment: The patient has a reported history of neurocognitive disorders (NCDs) with delirium and psychosis, refusing oral medications, no criteria for legal hold at this time, no criteria for forced medications at this time, the patient was still yelling out. All psychiatry consult visit had a documented the diagnoses of: NCD with behavior and anxiety, schizoaffective disorder bipolar type. Review of R81's nursing progress notes from 09/01/2024 to current, revealed the following behavioral incidences: - The resident continues to refuse medication and blood sugar check. The patient was yelling and screaming while in room. Very difficult to redirect, denies pain or discomfort. - The resident yelling loudly, hitting bathroom door, upset plumber and our maintenance director was in bathroom fixing the sink, staff and this writer tried to explain to resident but was unsuccessful resident continued to yell, hit the bathroom door threatening staff. - The resident continues to refuse all meds, and blood sugar this shift, can be heard yelling to self and staff in Spanish, maintenance in bathroom in resident room attempting to unclog toilet, maintenance swapped out toilet due to toilet and drains being clogged with multiple brown paper towels, staff member at room to translate for maintenance, resident states I have been throwing those paper towels in the toilet since I got here, staff member educated resident in Spanish on risk of clogging toilet, and encouraged resident to not do so, will continue to monitor. - The resident was heard yelling loudly. Upon entering room noted aide picking up soiled brief with stool off floor and wet paper towels from resident throwing onto the floor, resident very loud yelling and waving hands in the air pointing in this writer face then threw wet paper towel hitting me on the leg. - The resident continues to refuse all medications and blood sugar checks. The resident had an episode of yelling and screaming. The resident was peeking out of doorway cursing at staff members. Very difficult to redirect. Denies any pain or discomfort. Will continue to monitor. Resident 139 (R139) R139 was admitted on [DATE], with an admitting diagnoses including cerebral infarction due to thrombosis and Dementia. On 08/09/2024 at 9:55 AM, the resident was observed lying in bed. During the introduction R139 just looked and said nothing. On 08/11/2024 in the afternoon, an aide was sitting next to R139 for close monitoring due to residents' aggressive behavior. R139's admission History and Physical dated 06/02/2024, the patient had a history of dementia who recently developed cerebral venous thrombosis with subarachnoid hemorrhage. This is causing refractory strokes, started on antiepileptic and was eventually controlled. The patient was eventually controlled and transferred to this facility. The facility provided R139's Admission PASRR dated 11/29/2023, documented Determination: Dementia Alzheimer OBS. Psychiatric Evaluation dated 06/02/2024, documented Assessment: issues with anxiety and sleep, suggest monitoring, no suicidal ideation (SI) or homicidal ideation (HI), ongoing restlessness and anxiety, problems with mood and psychosis. Psychiatric Evaluation dated 09/01/2024, documented Assessment: Noted negative signs of psychosis (avoidance, agitation, withdrawn behavior). Ongoing combative behavior, kicking and spitting at staff members, problems with refusals, aggression noted, will continue to titrate medications to target, ongoing intermittent fatigue. All psychiatry consults visits had documented the diagnoses of: Major depressive disorder, single episode, severe with psychotic features. Review of R139's nursing progress notes from 09/01/2024 to current revealed the following behavioral incidences: - The resident was up most of the night pacing the hallways and wandering into other resident's room. Very difficult to redirect. The resident became physically aggressive at the staff. Assisted back to bed and 1:1 close observation provided. - The resident continues to pace quickly in the hallways running fast. Assisted patient to TV room for resting period. - The resident was monitored 1:1 supervision alternating staff due to aggressive behavior and to keep distance from other residents and aggressive behaviors for safety. - The resident pulled down brief and pants in dayroom and pooped onto the floor and urinated. On 09/10/24 at 3:03 AM, the Director of social services (SS) indicated PASRR 2 had to be completed for residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition. The Director acknowledged indications of behaviors and or diagnoses would place a resident into the criteria for a level 2 PASRR. The Director indicated SS is responsible in referring residents for level 2 in conjunction with the DON. The Director confirmed there were no residents currently being considered for a level 2 evaluation. On 09/11/2024 10:53 AM, the Director of Nursing (DON) confirmed the mentioned residents had the exhibited behaviors and diagnoses. The DON was not aware the residents did not have a PASRR level 2 completed. The DON reviewed the original PASRR and acknowledged the lack of the MI identified on the level 1 PASRR. The DON acknowledged the residents should have had a Level 2 completed to ensure the residents were appropriate for the facility and any recommendations were followed through. The DON indicated staff should have informed SS or DON so the application could have been submitted. 41903 Resident 119 (R119) R119 was admitted on [DATE] and readmitted on [DATE], with diagnosis including heart failure unspecified, urinary tract infection, and essential primary hypertension. On 09/09/2024 at 12:49 PM, R119 was observed in bed while watching television. R119 was pleasant, calm, and did not display concerning or withdrawn behaviors when interviewed. A Nevada PASRR Level I Identification Determination dated 11/04/2021, revealed R119 did not have dementia, mental illness (MI), mental retardation (MR) or any related condition (RC), and was deemed appropriate for nursing facility placement. R119's medical record revealed new diagnosis of anxiety disorder due to known physiological condition on 06/27/2023, anxiety disorder unspecified on 07/02/2023, panic disorder (episodic paroxysmal anxiety) on 07/03/2023, post-traumatic stress disorder unspecified on 07/03/2023, and major depressive disorder, recurrent severe without psychotic features on 08/02/2023. A Psychiatric Progress Note dated 08/16/2024, documented R119's affect was flat, withdrawn and had been isolating in the room. R119 was depressed and anxious at times. Assessment included R119 had occasional panic. R119's medical record lacked documented evidence a referral was made for PASRR level 2 evaluation after the newly found diagnoses listed above. On 09/11/2024 at 1:17 PM, the Director of Nursing confirmed R119 had new diagnosis of anxiety disorder due to known physiological condition, anxiety disorder unspecified, panic disorder (episodic paroxysmal anxiety), post-traumatic stress disorder unspecified, and major depressive disorder, recurrent severe without psychotic features. The DON acknowledged R119 should have been referred for PASRR level 2 evaluation based on the newfound diagnoses and behaviors displayed. A facility policy titled Social Services Policies and Procedures, PASARR Documentation Policy revised 06/09/2023, documented any resident with newly evident or possible serious mental disorder, intellectual disability (ID) or a related condition must be referred, by the facility to the appropriate state-designated mental health intellectual disability authority for review.

Based on observation, interview, record review and document review, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater for one unsampled resident (Resident 58) and 1 of 32 sampled residents (Resident 61). The deficient practice placed other residents at risk for medication errors. Findings include: On 09/10/2024 in the morning, a Medication Administration Pass observation was performed with 32 opportunities observed and revealed three errors. The medication error rate was 9.38%. Resident 58 (R58) R58 was admitted on [DATE] and readmitted on [DATE], with diagnoses including type two diabetes mellitus. On 09/10/2024 at 8:21 AM, the Licensed Practical Nurse (LPN) prepared and administered the following medications to R58: - Metformin hydrochloride (HCl) 500 milligrams (mg), one tablet - Aspirin 81mg chewable, one tablet - Vitamin B12 500 micrograms (mcg), two tablets - Docusate sodium 100 mg, one tablet - Sennosides with docusate sodium 8.6 mg, two tablets - Thiamine 100 mg, one tablet - Vitamin D 25 mcg 1,000 units, two tablets A physician's order dated 07/23/2024, documented to give Metformin 500 mg, one tablet by mouth twice a day at 7:00 AM and 7:00 PM, give with meals. On 09/10/2024 at 8:25 AM, there was no breakfast tray in R58's room. R58 indicated finishing breakfast about an hour ago. Resident 61 (R61) R61 was admitted on [DATE], with diagnoses including type two diabetes mellitus and schizoaffective disorder. On 09/10/2024 at 8:37 AM, the LPN prepared and administered the following medications to R61: - Metformin HCL 500 mg, two tablets - Aspirin 81 mg enteric coated, one tablet - Clopidogrel 75mg, one table - Cymbalta Duloxetine 30 mg delayed released, one tablet - Enoxaparin syringe 40 mg/0.4 milliliter (ml) injection - Famotidine acid reducer 20 mg, one tablet - Magnesium oxide 400 mg, one tablet - Pregabalin 75 mg, two tablets - Vitamin D3 25 mcg 1,000 units, four tablets A physician's order dated 07/23/2024, documented to give Metformin 500 mg two tablets by mouth twice a day at 7:00 am and 7:00 PM, give with meals. On 09/10/2024 at 8:40 AM, there was no breakfast tray in R61's room. R61 indicated finishing being done with breakfast more than an hour ago. Late medications/Not given with meals On 09/10/2024 at 8:42 AM, the LPN explained breakfast trays were delivered to the unit at 7:00 AM. The LPN indicated Metformin (anti-diabetic drug) was ordered to be given with meals for R58 and R61 because the medication decreased intestinal absorption of glucose. The LPN acknowledged administering R58's Metformin at 8:21 AM and R61's Metformin at 8:37 AM which was more than one hour after breakfast was served. The LPN explained being assigned 25 residents and the LPN acknowledged routinely administering 7:00 AM medications together with routine medications scheduled for 8:00 AM as a time-saving measure so the LPN would not need to enter a resident's room twice. On 09/10/2024 at 9:55 AM, the Unit Manager indicated Metformin was a diabetic medication typically ordered to be administered with meals to help control the resident's blood sugar by reducing the amount of glucose absorbed by the body. The Unit Manager indicated if it was not possible for the medication to be given during the actual mealtime, the LPN should at least try to administer the medication 30 minutes before or after a meal for efficacy. According to the Unit Manager the Metformin for R58 and R61 was not administered in accordance with physician's order when the medication was administered more than one hour after breakfast, and it was also considered a late administration since the facility expected medications to be given within one hour from scheduled time. On 09/10/2024 at 12:47 PM, the Director of Nursing (DON) indicated Metformin was typically ordered prior to or during meals because the drug bonded with food to decrease glucose levels in the body plus doing so reduced bowel side effects. The DON confirmed the Metformin for R58 and R61 were not given in accordance with the physician's order to give with food and in addition the medication was considered as late administrations since the medication which was scheduled for 7:00 AM were given to R58 at 8:21 AM and to R61 at 8:37 AM. The Mosby's Nursing Drug Reference handbook 2024 (37th edition) which was provided by the DON, revealed Metformin was an antidiabetic drug which inhibited hepatic glucose production and increased sensitivity of peripheral tissue to Insulin. Administer oral route with meals to decrease gastrointestinal upset and provide best absorption. The Medication Management Program policy revised 05/05/2023, documented nurses must understand indications or reason for use of therapy, effectiveness for achieving therapeutic goal, drug actions and the rights of medication administration which included right time. Medications were administered no more than one hour before to one hour after the designated medication pass times. Omitted/Missed dose On 09/10/2024 at 8:37 AM, the LPN administered nine routine medications to R61 except for Risperdal. A physician's order dated 09/02/2024, documented to give Risperdal 2 mg one tablet by mouth twice a day at 8:00 AM and 8:00 PM. On 09/10/2024 at 8:45 AM, the LPN indicated R61's Risperdal could not be administered due to the drug being unavailable. The LPN explained it was the LPN's first shift for the week and indicated expecting the previous nurses assigned to R61 to have replaced the resident's Risperdal to prevent a missed dose. The LPN indicated being trained to reorder medications which were running low, specifically when there were at least three days' worth of the medication remaining. The LPN indicated nurses could place orders electronically, by facsimile or by phone. On 09/10/2024 at 10:03 AM, the Unit Manager indicated nurses were expected to reorder medications when supply was running low to prevent missed doses. The Unit Manager indicated nurses may order electronically by clicking on the reorder button, by facsimile or placing a phone call to pharmacy. The Unit Manager pointed to the medication dispensing system in the medication storage room and indicated Risperdal was available in the form of 0.25 mg tablets. The Unit Manager indicated the LPN should have reached out to the physician for guidance on whether to administer eight Risperdal 0.25 mg tablets or to just wait for pharmacy delivery. The Unit Manager reviewed R61's medical record and confirmed the LPN had not reached out to the physician rendering R61's Risperdal as a missed dose which was not handled properly. On 09/10/2024 in the morning, the LPN acknowledged not reaching out to the physician regarding R61's missed Risperdal dose. The LPN indicated not having access to the medication dispensing system due to being newly employed in June 2024. The LPN indicated not being aware Risperdal was available in the medication dispensing system. On 09/10/2024 at 12:41 PM, a pharmacy representative arrived in the 200-Hall nurse's station to drop off medications. The pharmacy staff member indicated they made three deliveries a day and some emergency deliveries when needed. According to the pharmacy staff member, medications could be delivered within the day or the following day depending on what time the order was placed. On 09/10/24 at 2:17 PM, the Director of Nursing (DON) reviewed R61's medical record and confirmed the LPN had not notified the physician about the missed Risperdal dose this morning. The DON indicated nurses were trained to reorder medications when there was at least three days of medications left to avoid missed doses. According to the DON, Risperdal was an anti-psychotic medication which may affect the resident's mood and behavior and affect therapeutic levels when missed. The DON indicated missed doses were expected to be reported to the physician. The Medication shortages/Unavailable medications policy revised 08/01/2024, documented upon discovery of an inadequate supply of a medication, facility staff should initiate action to obtain the medication from pharmacy. If a medication was found to be unavailable, the nurse should obtain the supply from the medication dispensing system. If the medication could not be obtained through the emergency supply, the nurse should contact the physician to obtain new orders or directions for alternate administration.

Based on observation, interview, record review and document review, the facility failed to ensure gastrostomy (G-tube) care orders were entered and carried out in accordance with facility protocol for 1 of 32 sampled residents (Resident 79). The deficient practice placed the resident at risk for G-tube complications including but not limited to infection, malposition and discomfort. Findings include: Resident 79 (R79) R79 was admitted on [DATE] and readmitted on [DATE], with diagnoses including metabolic encephalopathy, gastroparesis and gastrostomy malfunction. On 09/09/2024 at 1:34 PM, R79 was awake and able to communicate. A bottle of Glucerna 1.5 and a water bag was hanging on a tube feeding (TF) pump with feeding tube looped around the machine. The Unit Manager indicated R79's enteral feeding schedule was to be started at 7:00 PM and terminated at 7:00 AM. A physician's order dated 05/24/2024, documented to give Glucerna 1.5 at 80 cubic centimeters (cc) per hour for 12 hours via percutaneous endoscopic gastrostomy (PEG) tube, start at 7:00 PM, end at 7:00 AM. Flush PEG with water at 60 cc per hour for 12 hours, start at 7:00 PM, end at 7:00 AM. On 09/11/2024 at 9:18 AM, R79 laid in bed with TF pump off but tubing was still attached to the resident's G-tube site. R79 pulled gown up which revealed a reddish-brown stain on the inner part of the gown and on the edges of the gauze dressing which covered the G-tube site labeled 09/11. On 09/11/2024 at 9:19 AM, the Licensed Practical Nurse (LPN) indicated terminating R79's enteral feeding earlier in the morning. The LPN indicated the tubing was not disconnected from R79 because R79 was holding on to the clamp and refused to be disconnected. On 09/11/2024 at 9:20 AM, R79 verbalized not refusing to be disconnected from the tubing. On 09/11/2024 at 9:20 AM, the LPN did not correct R79 when the resident denied refusing to be disconnected. The LPN confirmed there was a reddish-brown stain which appeared to be dried blood on the resident's gown and on the edges of the G-tube gauze dressing. The LPN indicated the night nurse reported there was drainage around R79's G-tube site but did not expound on the drainage. The LPN acknowledged not assessing R79's G-tube site during the termination of feed because the LPN trusted the night nurse's report there were no complications to the site. On 09/11/2024 at 9:22 AM, the LPN removed the gauze dressing which revealed bright red tissue around the stoma (surgical opening). Scant amount of bleeding was observed more pronounced when the LPN pressed around the stoma. R79 interrupted, I have pulled my G-tube before. On 09/11/2024 at 9:32 AM, the Wound Registered Nurse (RN) assessed R79's G-tube site and described the fresh tissue as hyper granulation which was caused by tissue growth from the inside which was not unusual for G-tube sites, however, the bleeding was not normal and should be reported to the wound nurse who would make recommendations and obtain orders from the wound physician. The wound nurse indicated if R79's G-tube condition was not identified and addressed now, it would have placed R79 at a higher risk for G-tube complications such as infection. On 09/11/2024 at 9:50 AM, the Director of Nursing (DON) entered R79's room, donned gloves and assessed R79's G-tube site. The DON described the tissue growth as fresh and beefy red which appeared to be hyper granulation. The DON indicated the agency LPN was expected to assess the site during termination of the enteral feeding and report the skin condition and bleeding to the wound nurse. The DON indicated nurses must do their own assessments rather than just rely on other nurse's report. On 09/11/2024 at 9:52 AM, the DON and wound nurse indicated R79 had a history of tugging on G-tube but refused an abdominal binder. The DON indicated assessing the site was more important for R79 due to other risks such as malposition and dislodgement. If the G-tube was mispositioned and feeding was initiated without proper assessment, the resident may be placed at risk for aspiration, bloating, discomfort and unnecessary hospitalization . On 09/11/2024 at 1:02 PM, the DON indicated having had the chance to review R79's medical record and confirmed no care orders were in place for R79's G-tube site care which should have included assessment and monitoring every shift, identifying and reporting abnormalities and cleansing and dressing changes. The DON indicated the resident was admitted with a G-tube on 02/18/2024 and there had been no care orders for the G-tube site ever since. According to the DON, any nurse who identified care orders were lacking and not in place could have obtained and transcribed care orders from a physician. The DON indicated the facility followed the [NAME] standards of practice for tube feeding. The Lippincott Nursing Procedures (9th edition), revealed G-tube site care included inspecting the tube for migration, signs of infection, pain and presence of drainage. If skin problems develop, consult the wound nurse.

Based on interview and record review, the facility failed to ensure 1) a resident was kept safe from physical abuse for 1 of 31 sampled residents (Resident 159); 2) nursing staff followed up on physician orders and monitored a resident who experienced a change in condition for 1 of 31 sampled residents (Resident 309) ; and 3) incontinence care was provided to 2 of 31 sampled residents (Resident 1 and 84) for seven hours. The deficient practice had the potential for the residents to not receive adequate care. Findings include: Resident #159 (R159) R159 was admitted on [DATE] and discharged on [DATE] with diagnoses including right lower extremity deep venous thrombosis, chronic kidney disease stage III, hypertension, history of non-sustained ventricular tachycardia, chronic low back pain with sciatica, diabetes mellitus type 2, history of COVID-19 viral infection, history of bronchitis due to COVID-19, and bilateral eye blindness, status post retinal detachment repair. A Nursing Progress Note dated 04/25/2023 at 9:12 PM, documented CNA (certified nursing assistant) reported resident was hard to arouse writer entered room noted that patient was non responsive when his name was called during assessment resident noted with carotid pulse and in distress using all accessory muscles with an oxygen saturation of 87% pulse of 189/128 with a heart rate of 28 writer called for a cash cart and for another nurse to call 911 non breather applied with 10 liters of oxygen patient is a full code blood sugar 220 paramedics arrived and took over care. A Nursing Progress Note dated 04/25/2023 at 11:57 PM, documented Spoke with ER (emergency room ) charge nurse stated patient has a diagnosis of encephalopathy and systemic inflammatory response syndrome and is going to be transferred to another hospital that can accommodate his needs as of now transfer hospital has not been confirmed. A Nursing Progress Notes dated 04/26/2023 at 3:19 PM, written by the Director of Nursing (DON) documented .Police Department arrived this morning at (name of facility) at 8:15 AM to investigate the injuries sustained by (R159) last night. DON not aware that he had been injured, was aware of COC (change of condition). (The police) informed DON of the severity of the injuries. At that time an internal investigation was initiated by the DON and Administrator. The required state report was completed and submitted timely. The facility physician Discharge Summary dated 04/25/2023 at 10:07 PM, documented the patient had a past medical history significant for hypertension, diabetes mellitus, previous COVID-19 infection, right lower extremity deep vein thrombosis, chronic kidney disease stage III, non-sustained ventricular tachycardia and chronic low back pain who was a long-term resident at the facility. During R159's stay at the facility, the resident had been receiving physical therapy, occupation therapy, and skilled nursing services. The resident was also followed by psychiatry, podiatry, and ophthalmology. The resident remained stable with multiple comorbidities. On 04/25/2023, I was notified that the resident was found unresponsive. The resident was transferred to the hospital for further evaluation and treatment. The hospital medical record revealed the resident had encephalopathy, unspecified systemic inflammatory response syndrome, mandibular fracture, and sternal fracture. On 08/31/2023 at 9:27 AM, the Director of Nursing revealed the resident did not have a fall prior to being transferred to the hospital. The resident had a change in condition (altered mental status, but no fall). The police and facility suspected R159 was beaten by someone. The facility was not aware of the extent of the resident's injuries until the police showed up to look at the crime scene. The DON was informed the hospital records documented the resident had a recent fall at the facility. The DON revealed the nurses did not indicate the resident had a fall. The nurse on duty did not know what happened to the resident. It was possible the resident's roommate might have told the Emergency Medical Technicians (EMTs) the resident had fallen. The resident was not on the floor, as the resident was a big man, it would have taken several staff to lift him off the floor to the bed. The resident's bed was in the lowest position. The facility began their investigation after being informed by the police of the injuries and could not find proof of how the resident sustained the injuries. After the incident, the resident's roommate was placed on a 1:1 for safety and was being followed by social services. R159's roommate was not aggressive and got along well with R159. As R159's roommate did not need the services of a skilled nursing facility and had spoken of wanting to discharge from the facility, the roommate was issued a 30-day discharge notice. Social services and Ombudsman worked with the resident to find an appropriate discharge location and social services checked in the resident to see how he was handling the incident. On 09/01/2023 at 2:15 PM, the Director of Nursing (DON) and the Administrator revealed R159, and roommate (R160) had been roommates for about a year. R159 could not get out of bed and could not fight back if attacked, R160 was ambulatory. The facility staff did not see any issues with the two residents and had no reason to suspect abuse. The facility placed R160 on a 1:1 observation after the incident and issued a 30-discharge notice. The resident had already intended to discharge and had the funds to transition back into the community. The police had found a decorative walking stick hidden on R160's side of the room, it blended in with the bed frame and was difficult to notice. The DON indicated the facility would try to not admit residents with aggressive behavior or been placed on a legal hold for aggressive or violent behavior. There were times when you would not know how the resident would behave when you admitted them to the facility. After the incident, the facility educated staff to be aware of things that were out of place such as a resident acting differently or new bruises and to inform leadership. If a resident did not get along with their roommate to listen to the resident and if they wanted to change rooms to have them meet the new roommate and then decide to change rooms. Staff were trained on abuse and neglect on orientation and the facility reviews abuse training with staff at least every quarter and during staff meetings. The DON and Administrator reported no other incidents. Resident #309 (R309) R309 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including acute metabolic encephalopathy, dysphagia status post (s/p) Percutaneous Endoscopic Gastrostomy Tube (PEG) placement, bacterial urinary tract infections s/p treatment, hypothyroidism, urinary retention, cerebral atrophy, seizure disorder, and hypo osmolar hyponatremia. A Nursing Progress Note dated 06/25/2023 at 1:25 AM, by the nightshift Licensed Practical Nurse (LPN) revealed the resident was sleeping all evening. Responded to name when called, just opens her eyes, turns her head, and shuts them back. Vital signs temperature febrile, 101.7 Fahrenheit. PEG tube site was cleaned of a moderate amount of brown drainage with soap and water, patted dry and secured with a drainage sponge. Foley catheter draining clear yellow urine with no sediment or foul odor. The physician was made aware. New orders included the following laboratory orders to be done in the morning: complete blood count, complete metabolic panel, magnesium level, erythrocyte sedimentation rate (could indicated possible inflammation in the body), C-Reactive Protein (CRP), Radiology: Chest x-ray and kidney, ureter, and bladder (KUB) to check g-tube position, urinalysis with culture and sensitivity, g-tube drainage culture, blood culture x2 and to run Dextrose (D)5 1/2 Normal Saline (NS) at 100 milliliters (mL)/hour until KUB results are in. Resident has no intravenous (IV) line at this time. A Nursing Progress Note dated 06/25/82023 at 1:30 AM, documented Urine collected for culture and sensitivity. A Nursing Progress Note dated 06/25/2023 at 3:55 AM, documented Resident has no IV line in place. Midline placement to be ordered in am. A Nursing Progress Note dated 06/25/2023 at 11:57 PM, documented pt (patient) send out per MD (medical doctor). WBC (white blood cell) 20.8 and gt (g-tube) malfunction. Sent to (name of hospital). Urinalysis with culture and sensitivity lab results report dated 06/25/2023 at 1:04 PM, documented abnormal test results. Handwritten on the document was to DC (discontinue) free water flush, consult ID (infectious disease) for Leukocytosis, DC D5 1/2 NS and start NS at 80 cc (cubic centimeters)/hour, daily renal and mag (magnesium) panel x5 days, NP (nurse practitioner) notified as 06/25/23. The C-Reactive Protein, Magnesium lab results report dated 06/25/2023 at 1:10 PM, documented abnormal results. Handwritten on the document was NP notified as 06/25/2023. The Sedimentation Rate lab results were reported on 06/25/2023 at 2:03 PM with abnormal results. The Comprehensive Metabolic Panel lab results report dated 06/25/2023 at 1:10 PM documented abnormal results. Handwritten on the document was NP notified as 06/25/2023. The Complete Blood Count with differential lab results report dated 06/25/2023 at 2:26 PM documented abnormal results. Handwritten on the document was NP notified as 06/25/2023. The Blood Culture report was pending. A review of the orders from 06/23/2023 to 06/25/2023, documented the following orders: - D5 1/2 NS at 100 mL/hour via intravenous. - Midline placement for IV fluids - Blood Culture x2, CBC, CMP, CRP, Magnesium, ESR, urinalysis with culture and sensitivity - CBC with differential, Renal Function Panel - Standard abdomen/KUB - Standard chest x-ray Vital signs taken on 06/25/2023 at 8:20 AM documented a blood pressure (BP) 119/73, pulse 79, Oxygen saturation (O2 Sat) 98, no temperature or respiratory rate was documented. Vital signs taken on 06/24/2023 at 7:59 PM, documented an O2 Sat of 95%, no other vitals were documented. The facility physician Discharge Summary dated 06/25/2023 at 10:45 PM, documented the resident was transferred to the hospital for diagnoses including altered mental status and sepsis. The resident was transferred to an acute care hospital for further evaluation and treatment. On 6/25/2023, the resident was found to have a fever of 101.7 Fahrenheit. Stat (immediate) labs were ordered. Chest x-ray and KUB were also ordered. IVF (intravenous fluid) was also ordered. The resident's labs came back critical with a white blood cell count of 20.8. The facility was unable to establish an IV access. Therefore, the resident was transferred to the hospital for further evaluation and treatment. The clinical record lacked documentation of the resident's status from 06/25/2023 at 3:55 AM to 10:45 PM when the physician was notified, and new orders given to send resident out. On 09/01/2023 at 2:15 PM, the Director of Nursing (DON) and the Administrator revealed the LPN did not call-in radiology test request, forms were not completed, the LPN wrote more in the progress note than was carried out. The LPN did not give a full report to the oncoming LPN of the resident's status and orders which needed to be followed up on and carried out. The physician kept calling the facility requesting results of the lab work and the LPN kept indicating the results were not available. The LPN did not follow up and the 24-hour report was not updated. The nightshift nurse came in and identified a change in condition and notified the physician and the resident was sent out to the hospital. An investigation was conducted and verified the allegation of neglect. The oncoming LPN did not talk to the facility after being suspended pending the investigation of neglect. The two nurses were terminated and reported to the Board of Nursing. After the incident the facility conducted training on change of condition, carrying out physician orders, follow up on orders, LPN could not give another LPN orders to carry out, and documentation of the follow up. Leadership was out on the floor more and asking questions about resident status and ensuring the nurses were following up on residents with a change of condition and new orders. DON had provided the staff with reasons to call the on-call administrator to let them know what was going on, so follow-up could occur, the 24-nursing report was being turned in each day and reviewed in daily stand up. During the survey, the facility had educated staff and implemented the 24-hour nursing report as identified in the corrective action. There were no reported abuse/injury of unknown origin to the extent of a resident being hospitalized and staff were following up and documenting resident change of condition status. The facility policy titled Documentation - Licensed Nursing revised on 05/05/2023, documented the 24-hour report would reflect any status changes, changes in resident conditions, and notification and the verification of documentation of any changes according to the Facility Practice Guidelines, and state specific rules and regulations when indicated. The qualified nurses in each unit complete the 24-Hour Report, on each shift 7 days per week. The facility policy titled Abuse, Neglect, Exploitation, or Mistreatment (undated) documented abuse was the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect was the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical, harm, pain, mental anguish, or emotional distress. 33980 Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including retention of urine, personal history of traumatic brain injury, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The Quarterly Minimum Data Set (MDS) dated [DATE], documented R1 had impairment on both sides of upper and lower extremities and always incontinent with bowel and bladder (urinary). R1 required extensive assistance, two persons physical assist with toilet use, and total dependence, two persons physical assist with personal hygiene. Resident 84 (R84) R84 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pressure ulcer of sacral region (Stage 3), metabolic encephalopathy, and major depressive disorder, recurrent, severe with psychotic symptoms. The Quarterly MDS dated [DATE], documented R84 had impairment on one side of upper and lower extremities and always incontinent with bowel and bladder. R84 required extensive assistance, one person physical assist with toilet use and personal hygiene. The final Facility Reported Incident (FRI) dated 07/18/2023, documented the following: - An allegation of neglect which occurred on 07/12/2023 was investigated. A Certified Nursing Assistant (CNA) did not go into the room to provide care to two total care residents (R1 and R84) until seven hours or more after the start of the shift. - The CNA substantiated the allegation and admitted to not caring for either resident for several hours during the shift. - The CNA was terminated at the conclusion of the investigation on 07/18/2023. - The allegation against the CNA was verified (substantiated) by the facility and the State Board of Nursing (BON) was notified. On 09/01/23 at 2:17 PM, the Director of Nursing (DON) revealed the CNA was scheduled to work on day shift, from 6:00 AM to 6:00 PM, on 07/12/2023. The DON confirmed the CNA admitted R1 and R84 were not changed or not provided with incontinence care from 6:00 AM to 2:00 PM. The DON indicated the two residents were incontinent and required total care. The DON revealed the CNA was suspended pending investigation then terminated upon the conclusion of the investigation. The CNA was reported to the State BON regarding the incident. The DON explained the CNAs were expected to do check and change (incontinence care) every two hours. The licensed nurses were expected to supervise the CNAs and made sure the residents were provided with incontinence care. During the onsite investigation on 08/30/2023 through 09/01/2023, the facility's correction of the past non-compliance related to the incident occurred as evidenced by: - Observation of grooming and physical appearance of residents, including the residents of concern, revealed there were no residents observed with foul-smelling odor. Residents who were interviewed, including R84, acknowledged the staff attended to their needs. - A CNA and a Licensed Practical Nurse (LPN) explained the residents who were incontinent with bowel and bladder were checked and changed every two hours. The nurses and CNAs would have done the rounds alternately at least every one to two hours to ensure the residents were safe, comfortable, and not wet. The CNA and the LPN indicated the facility provided continuing education regarding resident rights and prevention of abuse and neglect. Facility Reported Incident #NV00068924, #NV00068455, and #NV00068988.

Based on interview, record review and document review the facility failed to provide necessary care for 1 of 5 sample residents (Resident 1) in a universe of 178, which resulted in the resident's death. Findings include: On [DATE] the facility reported an incident that occurred on the morning of [DATE] in which Resident 1 was found by staff in her room unresponsive. Paramedics were called and the licensed staff immediately started CPR on Resident 1. The paramedics transported Resident 1 to an acute care facility where she expired from [MEDICAL CONDITION]. Resident 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A physicians order dated [DATE] indicated the resident required 1:1 feeding assistance. The Nutritional assessment conducted by the registered dietician dated [DATE] indicated that the resident had chewing difficulties and was on a mechanical soft diet. The facility's investigation revealed CNA 1 was assigned to pass the meal trays and feed the residents who need assistance in their rooms, which included Resident 1. Per the statement of CNA 1, she was feeding Resident 1 at approximately 7:30AM and then left to go finish passing the trays to the other residents before Resident 1 was finished with her meal. Per the facility investigation, CNA 1 did not check to make sure Resident 1 had completely chewed all her food and swallowed before leaving the room. At 8 AM staff found Resident 1 unresponsive and called code Blue. According to the facilities investigation CNA 1 did not check on Resident 1 from the time she left the resident at 7:30AM till code blue was called at 8 AM. The facility indicated CNA 1 was negligent by leaving Resident 1, who required a direct 1:1 feeding assistance before she finished swallowing her food and ensuring the head of the bed was elevated to the proper feeding position. The head of the bed was elevated only 30 degrees when CNA 1 left the resident without ensuring the resident swallowed her food. According to interviews with the Administrator and charge nurse, CNA 1 was found negligent in leaving Resident 1 without checking to ensure she had swallowed her food before leaving her alone in bed based on facility policy for direct care feeding. The Administrator indicated and provided documentation the Nursing Board had been notified in regards to CNA 1's negligence by leaving Resident 1 before ensuring she had swallowed her food.

Based on interview, record review and document review, the facility failed to ensure a resident with a full code status was timely assessed and basic life support provided after having been found unresponsive for 1 of 6 sampled residents (Resident #1). Finding include: Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. A Nurses Note dated [DATE] at 8:55 PM, documented the resident was found unresponsive in a shower room. The note indicated cardiopulmonary resuscitation (CPR) was initiated and 911 called for help. The note revealed the paramedics arrived at 9:05 PM and provided CPR until 9:30 PM when the maneuver was terminated due to the unsuccessful resuscitation. On [DATE] at 11:11 AM, the Director of Nursing (DON) explained a report was received about the incident when the resident was found unresponsive. Resident #1 was taking a shower about 8:30 PM. A Registered Nurse (RN) found the resident on the floor inside the shower. The RN did not check the resident, the RN called a Certified Nursing Assistant (CNA) and indicated a resident was on the floor in the shower room. The RN left the CNA along with the resident. The DON indicated the CNA checked the resident and found the resident was unresponsive. The CNA called a Licensed Practical Nurse (LPN) and CPR was initiated 911 was called. The paramedics arrived and continued CPR but after 30 minutes, the paramedics stopped the procedure and pronounced the resident. The DON explained after receiving the report about the incident, an investigation was performed. During the investigation, the RN was interviewed and affirmed she did not check the resident because the resident seemed to be dead. The DON mentioned the RN was terminated due to not follow the facility policies and Nursing Practice Act. The DON confirmed the RN was reported to the Nevada State Board of Nursing for negligence. On [DATE] at 11:30 AM, a telephone interview was conducted with the LPN on duty on the day when the incident happened. The LPN indicated on [DATE] about 9:00 PM, a CNA notified her a resident was unresponsive on the floor in a shower room. The LPN immediately went to the nurses ' station and reported to the RN who replied she had been aware of the situation and the resident already had gone. The LPN indicated, the RN verbalized the resident was pronounced because it seemed to be death. The LPN checked the clinical record and found out the resident was a full code. Immediately the LPN called 911 and the RN ran to the shower room with a crash cart and initiated the CPR. The LPN confirmed the CPR was initiated three to five minutes later after the resident was found unresponsive. On [DATE] at 1:15 AM, a telephone interview was conducted with the CNA on duty on the day the incident happened. The CNA indicated while walking down the hall way, he observed the RN coming out from the shower room. The RN called him and notified him a resident was on the floor. The CNA explained the RN told him the resident was gone he is gone and walked away. Since the CNA did not know what to do, he called a LPN who went to the nurses ' station and notified the RN. After about three to five minutes the RN and LPN came to the shower room and initiated the CPR. Review of facility policies entitled Do Not Resuscitate (DNR) dated [DATE], documented that in absent of a DNR order, the facility staff would respond to medical emergencies with CPR and a Full Code will be instituted.

Based on record review and interviews, the facility failed to ensure current weights were utilized in evaluating and planning for a resident with repeated episodes of significant weight loss for 1 of 26 sampled residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The policy, Weighing The Resident, revised 9/2011, documented the procedure for weighing a resident for admission or readmission included, the resident must be weighed within 24 hours of admission, daily for three days, weekly for three weeks and monthly and/or per physician orders. If the month to month weight shows more than a five percent gain or loss, the patient/resident is re-weighed within 24 hours. If there is an actual 5% or more gain or loss in one month, notify the patient/resident/family, physician, and the Nutrition/Culinary Services Director. Document this notification per facility protocol. The Weight Variance Report documented: - 10/06/14 154.6 pounds (lbs). - 10/07/14 154.5 lbs - 10/08/14 154.5 lbs - 10/20/14 146.8 - documented as a 5% weight loss The clinical record lacked documented evidence the resident was re-weighed within 24 hours of the 5% weight loss, weekly weights were done on 10/15/14 and 10/29/15, or if the physician was notified of the weight loss. The clinical record lacked documented evidence the resident was weighed seven days later on 10/27/14. The Registered Dietician's (RD) Nutritional Progress Notes for 10/19/14 documented a weight of 154.5 lbs from the documented 10/7/14 weight, noting no recent weight loss found. The RD Nutritional Profess Note dated 11/2/14 documented a weight of 146.80 lbs which was from the previous weight documented on 10/20/14, noting the loss of 5%. The notes lacked documented evidence of resident, family or physician notification of the 5% weight loss and a reweigh within 24 hours per policy. Resident #8 was discharged on [DATE] to a hospital. At the time of the discharge, an SBAR (Situation, Background, Assessment, Response) Communication Form reported the resident's weight was 126.8 lbs reporting a significant weight loss of 22 lbs in seventeen days. The resident was readmitted to the facility on [DATE]. The resident was weighed three days after admission to the facility on [DATE] with a weight of 122.10 lbs. The Weight Variance Report lacked documented evidence the resident was weighed within 24 hours of admission or daily for three days. The resident was discharged on [DATE] and readmitted on [DATE]. The reported weight on 12/29/14 was 130.4 lbs, on 12/30/14 the weight decreased to 127.6 lbs, on 12/31/14 the weight decreased to 126.8 lbs. The Weight Variance Report lacked documented evidence the resident was weighed within 24 hours of being readmitted . The resident was discharged on [DATE] and readmitted on [DATE] with a [DEVICE], no food by mouth. The Weight Variance report documented the resident weighed 132.4 lbs on 1/10/15, 134 lbs on 1/11/15, and 133.4 lbs on 1/13/15. The Nutritional Progress Notes from the RD written on 1/22/15 documented the resident had a weight of 133.4 lbs, which was the documented weight from 1/13/15. The RD documented the weight was stable and to continue with the current plan. The Weight Variance Report documented the resident was weighed on 2/4/15 with a weight of 118.2 lbs, a documented 6.9% weight loss. The medical record lacked documented evidence of the resident being weighed within 24 hours of the documented 6.9% weight loss. On 3/5/15 the resident's documented weight was 120.4 lbs, on 4/4/15 the weight was 110.6 lbs, on 4/6/15 the weight was 110.6 lbs, and on 5/5/15 the weight was 110.0 lbs. The Nutritional Progress Notes from the RD on 2/5/15 documented the weight of 133.4 lbs and to continue the tube feeding treatment. This reported weight contradicted the documented weight of 118.2 lbs on 2/4/15 reported on the Weight Variance report. On 2/19/15 the RD documented the resident's Glucerna to be increased to 1.2 at 80 cc (cubic centimeters) for 20 hours (1600 cc/1920 Kcals) provides 96 grams of protein. The final note on 4/28/15 documented the resident's weight of 110.6 lbs with Glucerna being increased to 1.5 at 70 cc for 20 providing 2100 K-cals, 115 grams of protein (started on 3/31/15). On 5/13/15 at 4:45 PM, the Registered Dietician (RD) explained the nurses notified the dietician and the physician in regards to a 5% weight loss. The RD confirmed the policy to weigh a resident within 24 hours of admission and readmission, daily for three days, weekly for three weeks, monthly and/or per physician orders, and if there was a significant weight loss, the physician was to be notified. The RD explained a readmission was considered a new admission. The RD was unaware of why a current weight was not requested on 11/02/14. The RD explained the resident was on the wrong solution at the hospital prior to the resident's readmit to the facility on [DATE]. A request was made of the RD to speak with the resident's physician, with no response. A request was made for additional policies pertaining to weight loss monitoring and significant weight loss interventions, none were provided. The RD documented on the Evaluation/Nutritional report for the readmit on 01/09/15, the resident was dependent on Enteral nutrition for 100% of nutritional needs and to continue to monitor weights and feeding tolerance. The RD documented on the Dietary Enteral Evaluation, on 03/31/15, weight of 120.4 lbs, which was documented from the Weight Variance Report on 3/5/15 noting this was a weight loss trend. The next documentation was on 4/9/15 with a weight of 110.6 lbs, which was documented from the Weight Variance Report on 4/6/15 with a note reporting this was a significant weight loss. On 4/9/15, the RD documented the resident's weight to be taken weekly with an expectation of weight gain. The Weight Variance Report showed the weights were not taken weekly after 4/9/15. The clinical record lacked documented evidence of resident, family or physician notification of the significant weight loss reported in March and April 2015. The resident had a 22.4 lb weight loss between the weight documented on admittance of 1/9/15 of 132.4 lbs to the last documented weight on 5/5/15 of 110.0 lbs. On 5/14/15 in the morning, a request was made to the RD to interview with the resident's physician. The RD replied the physician would be paged. No response from the RD or physician was received. On 5/14/15 at 11:55 AM, the Director of Nursing (DON), a Licensed Practical Nurse (LPN), the Clinical Nursing Director and the RD confirmed the resident should have been re-weighed on 10/20/14 and when there was a significant weight loss reported. They all confirmed the resident should have been weighed weekly for three weeks after admission in October 2014 and weighed weekly after the readmit on 1/9/15. They were unaware if the physician had been notified on 11/02/14 after the first documented 5% weight loss. A request was made for additional policies pertaining to weight loss monitoring and significant weight loss interventions, none were provided. The policy, Meal Intake Documentation, Patients/Residents at Nutritional Risk, revised 9/2012, documented to observe all meal intake for residents assigned. A meal intake analysis is completed and each meal is evaluated to determine how much of the meal was consumed. The Data Collection/Evaluation-Nutritional report for 10/12/14 documented the RD ordered by mouth (PO) intake to be monitored and evaluated. For the Meal percentage report which contained meal monitoring for October 2014, breakfast was not documented 6 times, Lunch was not documented 7 times and dinner was not documented 10 times. In November 2014, breakfast was not documented 4 times, lunch was not documented 9 times and dinner was not documented 3 times. The clinical record lacked documented evidence the resident's [DEVICE] (GT) feedings were documented in 2015. On 5/14/15 at 12:04 PM, the DON confirmed the policy was not followed for weighing the resident and the charting of all meals for October and November 2014. The DON confirmed this was not acceptable.

Based on measurement, observation and interview, the facility failed to ensure the hot water temperatures in the residents' bathroom sinks and shower room(s) were maintained at a safe level (less than 120 degrees Fahrenheit (F)). Findings include: An Immediate Jeopardy (IJ) was called on April 23, 2014 at 9:38 AM due to unsafe water temperatures in the secured unit. On April 23, 2014 at 5:06 PM, the facility provided an acceptable plan of correction for the immediate jeopardy situation. The immediate jeopardy was abated on April 23, 2014 at 5:06 PM. Note: All temperatures are given in the Fahrenheit (F) scale. On 4/23/14 at 6:27 AM, the water temperature in the 100 Hall medication room registered 119 degrees Fahrenheit. The temperature was confirmed by the Licensed Practical Nurse (LPN). On 4/23/14 at 7:00 AM, the bathroom sink water in Room 113 registered 124 degrees Fahrenheit. The temperature was confirmed by the LPN. On 4/23/14 at 7:18 AM, the Certified Nursing Assistant (CNA) explained the water temperature seemed hot for the last "week or so" in some of the residents bathrooms. The CNA explained the water temperatures were hotter after the facility fixed the shower in the 100 Hall. On 4/23/14 at 7:26 AM, the bathroom sink water in Room 119 registered 122 degrees Fahrenheit. The temperature was confirmed by the LPN. On 4/23/14 at 7:29 AM, the shower room sink water registered 120 degrees Fahrenheit. On 4/23/14 at 8:35 AM, the CNA explained one resident was known to go into residents bathrooms and turn on the water. On 4/23/14 at 8:40 AM, the resident in Room 117A was heard saying "burning hot water-someone turned the water too hot." On 4/24/14 at 8:55 AM, the Certified Nursing Assistant (CNA) in the 100 Hall confirmed the hot water temperature had not been reported to management. The facility's Policy and Procedure, "Domestic Hot Water Temperature," dated 3/2006, indicated, "1. The Facility shall maintain domestic hot water temperature at 105 - 120 degrees at the outlet, or per State regulations." (Note: Nevada state regulations for resident care areas in skilled nursing facilities for hot water temperatures range 95-110 degrees Fahrenheit.) On 4/23/14 in the morning, the Director of Maintenance indicated the acceptable range for water temperatures was 105 to 120 degrees Fahrenheit (F). The Director of Maintenance indicated he did not know what the State requirement was for acceptable temperature ranges. 100 Hall - The 100 Hall is a locked unit for residents with dementia. On 4/23/14 at 8:15 AM until approximately 9:15 AM there were demented residents roaming the halls and going in and out of other residents' rooms. On 4/23/14 at 8:15 AM, the Director of Maintenance took temperature readings in the 100 Hall. The Director of Maintenance was observed to place the thermometer under the water flow for only 7-10 seconds, while the water temperature reading was still increasing and had not yet stabilized. The Director of Maintenance indicated he regularly took temperature readings by turning off the water after 10 seconds. The temperatures were re-measured, with the following out of range temperatures identified: -8:20 AM: Room 122: 129 degrees F within 20 seconds, 30 seconds, and 60 seconds. -8:22 AM: Shower Room: 122 degrees F within 20 seconds, 30 seconds, and 60 seconds. -8:37 AM: Bathroom near the Nurse's Station: 126 degrees F within 20 seconds. The door to this bathroom was unlocked, and a demented resident was observed walking into the bathroom unsupervised. At approximately 8:10 AM, three employees (2 Certified Nursing Assistants (CNA's) and 1 Housekeeper) were interviewed, who indicated the water from the residents' rooms and the shower was very hot. One CNA indicated the water had been very hot for the past 2 weeks, and 1 CNA indicated it had been very hot for the past 3 days. The Director of Maintenance verified the Room 122 water temperature of 129 degrees F and indicated, "If the water's running high in this room it's gonna (sic) be like that for every room. It's on the same boiler." 200 Hall: At approximately 8:35 AM, the Maintenance Assistant began taking water temperature readings in the 200 Hall. The Maintenance Assistant was observed to place the thermometer under the water flow for only 8 to 10 seconds, while the water temperature reading was still increasing and had not yet stabilized. The Maintenance Assistant indicated he regularly took temperature readings by turning off the water after about 12 to 15 seconds. The temperatures were re-measured, with the following out of range temperatures identified: -8:37 AM: Room 245: 113 degrees F after 20 seconds, 30 seconds, and 60 seconds. -8:39 AM: Room 239: 113 degrees F after 20 seconds, 30 seconds, and 60 seconds. -8:40 AM: Room 231: 115 degrees F after 20 seconds, 30 seconds, and 60 seconds. -8:41 AM: Room 227: 112 degrees F after 20 seconds, 30 seconds, and 60 seconds. -At approximately 8:50 AM, in Room 234 the water temperature was 114 degrees F within 60 seconds. On 4/24/14 at approximately 12:00 PM, the water temperature in the Men's Bathroom near the Lobby was 126 degrees F within 20 seconds. The Director of Maintenance indicated there were four hot water heaters throughout the facility: - One hot water heater located next to the 100 Hall Shower Room, servicing the 100 Hall. - One hot water heater servicing the Laundry. - One hot water heater located in the Maintenance Office, with two mixer valves. One of the mixer valves serviced the 200 Hall / Ancillary Areas, and one of the mixer valves serviced the kitchen. - One hot water heater located in the 300 Hall, servicing the 300 Hall. On 4/23/14 and 4/24/14, the mixer valve which serviced the 200 hall, located in the Maintenance Office, appeared corroded and deteriorated, with evidence of severe water leakage. (Water was observed leaking from the valve) The Director of Maintenance indicated the mixer valve had been in this condition since he had been hired in October 2013. He further indicated the previous Director of Maintenance had told him the mixer valve had been in deteriorating condition and broken for "a while." Upon questioning whether the Administrator was made aware of the broken mixing valve, the Director of Maintenance indicated he had not told the Administrator, but that the previous Director of Maintenance had submitted a request to Administration, but it was denied because it was too expensive. The Director of Maintenance was unable to provide documented evidence a plumbing company had assessed the mixer valves until 4/23/14 in the afternoon. The plumbing company invoice indicated, "Inspected 2 thermostatic valves. The 1 1/2" valve is in need of replacement and the 3/4" is on the verge of replacement." The Director of Maintenance indicated the two valves referred to in the plumbing company's invoice was the one located in the Maintenance Office and the one located in the 100 Hall. Further interview regarding why the mixer valve for the 300 Hall was not assessed by the plumber, the Director of Maintenance indicated, "Because there's no problems with that one. You don't take your car to a mechanic if there's nothing wrong with it." On 4/23/14 in the afternoon, the mixer valve servicing the 300 Hall appeared severely corroded, with evidence of water leakage. On 4/23/14 and 4/24/14, the facility's Monthly PM (Preventative Maintenance) Inspection Checklists were reviewed with the Director of Maintenance, which documented the facility was aware of the broken mixing valves since October of 2013 and had not taken any action to repair them: -10/31/13: "Missing valves - small leak at main mixing valve." -11/26/13: "Hot Water Heaters: Need new mixing valve, needs replaced." -12/30/13: "Hot Water Heaters: Need new mixing valve. Mixing valves needs repaired or replaced." -1/28/14: "Hot Water Heaters: Need new mixing valve. Mixing valve not functioning correctly." -2/27/14: "Hot Water Heaters: Mixing valves: Inconsistent temp (temperature) control." -3/28/14: "Hot Water Heaters: Need new thermometer."

Based on clinical record review, interview and policy review, the facility did not ensure physician orders [REDACTED].#1, #5, #18, #30, #31, #32, #33, #34, #35, #36, #38 and #39). Findings include: Resident #1: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged to an acute care facility on 4/26/12 at 12:30 AM, for unstable vital signs: body temperature of 98.0 degrees, pulse of 42 beats per minute, respiratory rate of 30 breaths per minute, systolic blood pressure of 80 millimeters of mercury (mmHg) over an undeterminable diastolic blood pressure. The "Nurse's Note" dated 4/25/12, during the 2-10 Shift (PM), indicated the licensed nurse observed a [MEDICAL CONDITION] episode at 4:30 PM, the incident lasted less than two minutes, the resident's vital signs included a blood pressure of 110/60, temperature of 98 degrees, pulse of 88 beats per minute, respirations of 26 breaths per minute, and an observation by the licensed nurse that the Resident's "left breast swollen"; notified Resident #1's physician. The physician ordered laboratory tests and an ultrasound of the left breast, and oxygen (O2) to be administered at 2 liters per minute through a nasal cannula to keep the resident's O2 sat (saturation level) above 92%. There was no documentation referring to a bandage on Resident #1's left arm. The Nurse's Note dated 4/26/2012, at 12:30 AM, stated, "PT. (patient) was sent out to (name of receiving acute facility) for possible internal bleeding, PT. was assessed on (night shift) at 2200 hrs (10:00 PM). (Blood pressure) was unreadable at this time, O2 sat +96%, PT. was put on 15 (liters per minute of O2) by (evening nurse). When O2 was (down arrow) to 3 (liters per minute) PT. desaturated = 84% Pulse was weak & shallow, by 2300 (11:00 PM) PT. was resting, (without complaints of) pain, O2 was holding @ 95% on 6 (liters per minute). @ 0000 (12:00 AM) I took BP (blood pressure) & pulse again, BP=80 systolic & (no diastolic) pressure, (heart rate) = 42, (respirations) = 30, (left) breast was swollen & hard to the touch, also large area of bruising noted @ (left) breast and moving to (left) arm, RN (Registered Nurse) supervisor alerted & PT. was sent out, family, (doctor), & (administrator) notified per the RN on duty". On 5/16/2012, at 10:00 AM, The Director of Nursing (DON) was interviewed. She reviewed the Nurse's Notes written on 4/25/12 and 4/26/12 by the licensed nurses. The Director of Nursing stated the nurse should have notified Resident #1's physician of the resident's need for 15 liters per minute of Oxygen. Employee #1 stated the nurse should have notified Resident #1's physician at 10:00 PM when her blood pressure was "unreadable" and of the resident's need for more Oxygen than the ordered 2 liters per minute. The DON indicated the nurses should have notified Resident #1's physician when the resident required Oxygen at more than the ordered 2 liters per minute per nursing practice. On 05/16/2012, DON was asked for the facility's oxygen administration policy. The DON provided a copy of Mosby's Chapter #22 titled "Oxygen Therapy", which stated in part, "Oxygen is regarded as a medication. Increasing the oxygen liter flow rate for shortness of breath is similar to doubling heart, asthma, or other medications..." (page 765). Clinical records from the acute facility to which Resident #1 was admitted were reviewed. The document titled "Nursing Documentation: Triage", dated 4/26/12 at 12:40 AM, indicated Resident #1 sustained "trauma" that consisted of a "fall". The document titled "Emergency Physician Record: Shortness of Breath", dated 4/26/12, at 12:42 AM, stated in part, "EMS (Emergency Medical Services) was called to SNF (Skilled Nursing Facility) for (patient) having a syncopal episode and fall with injury to left breast and shoulder (yesterday) AM. Pt (patient) was on NRB (non-rebreather mask) at SNF thru the day and apparently became worse. When EMS arrived pt was hypotensive and had a O2 stat of 75%. Pt is unresponsive no other hx available". The facility failed to ensure an ongoing assessment of a change in resident condition. There was a lack of documentation from 4/25/12 at 4:30 PM to 12:00 AM on 4/26/12, of an assessment of Resident #1's swollen left breast, or of Resident #1's [MEDICAL CONDITION] episode, or increased demand for oxygen supplementation. The DON stated the facility was conducting an ongoing investigation of the origin of the underarm bruise. The DON verified there was no documentation of a dressing or injury on Resident #1's left upper arm, but concurred that staff mentioned the dressing on the resident's arm was present while Resident #1 was at the facility. An interview conducted on 5/15/12 at 1:15 PM with Resident #23 indicated that she was the roommate of Resident #1 when the fall occurred. Resident #23 stated: -"She (Resident #1) passed out as she was being put up on the Sera Lift. She hit the handle bars and they got her back in the bed. -I was told to go to the room across the hallway and I was able to see them from the door into our room. -I was allowed to come back in and I sat next to her on a chair between our beds. -They (day shift House Supervisor and LPN (Licensed Practical Nurse) gave her O2 (oxygen). -18 different times in 8 hours I hollered down the hallway to call the House Supervisor or the LPN to tell them that she was not breathing okay and to get her transferred to the hospital. -I asked the House Supervisor to smell her breath. She (Resident #1) had a smell to it. -Both of them (House Supervisor and LPN) kept telling me, "She was fine and we got it covered." -When the night shift House Supervisor came, I called her because she (Resident #1) got clammy and was hyperventilating. That was the first time she was checked head to toe. -Her left breast was swollen three times larger than the right breast. It was black from her hip to her armpit." Resident #3: The policy titled "Physician Communication/Change In Condition" was reviewed on 5/18/12. The policy stated in part, "Notify the physician of the change in medical condition...If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified. The Medical Director will provide medical orders as necessary to treat the patient's/resident's condition". Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged to an acute care facility on 3/01/12, due to altered mental status. Documentation indicated that on 2/29/12, Resident #3 did not receive her intravenous (IV) antibiotic because her IV needed to be removed and staff was unable to gain access with another IV. The resident was given a peripheral intravenous central catheter (PICC) line the next day. Resident #3's Nurse's Note, dated 3/01/12, indicated that Resident #3 had a fever and the doctor was paged. Before the order for Tylenol was received, the note stated, "Residents family wanted to know why it was taking so long to give Tylenol. It was explained that we could not give any medications (without) a doctor's order". The physician was paged again with no response. The note continued, "Residents family voiced their complaints that Tylenol needs to be given or they were going to call an ambulance to take their mother to the ER. "Gerinet" the physician group, was paged again two more times without any response from the (doctor or physician's assistant. House supervisor) had to call and ask to speak to an administrator "stat" (as soon as possible and) have the (physician's assistant) paged stat. Gerinet was unable to get a hold of the on-call (physician's assistant) and had another (physician's assistant) give orders for this resident. Daughter had left in the meantime to go and buy Tylenol from the store to give to resident. While daughter was gone new orders from (the physician's assistant) were gotten (sic) Tylenol for temp of >101 and DW5 @ 60 cc/hour for fluids to supplement her oral consumption of fluids. Tylenol was given and antibiotics and fluid was hung. Temperature had gone down after Tylenol was given. Resident's mother (sic) came to the nursing station and asked for the nurse to come see her mother saying she was all sweaty. Nurse saw that resident's clothes were damp and resident was lethargic and slow to respond to voice or physical stimulus..." The note indicated that the physician was notified and the resident was transferred to the emergency room . The Director of Nursing (DON), was interviewed on 5/31/12, at 12:40 PM. The DON stated she remembered being contacted when nursing staff did not receive physician response to their paging attempts. She advised them to contact the medical director. She stated if there was no response after three attempts to contact the physician, the Don and Medical Director should be contacted. She indicated did not know how long the nurses waited before contacting her and that the timeline was not documented in the Nurse's Note. Unsampled Residents #32, #33, #34, #35 and #36: An observation on 5/16/12 at 11:58 AM, lunch time at the facility main dining room, indicated five (5) unsampled residents (Resident #32, Resident #33, Resident #34, Resident #35, Resident #36), receiving oxygen therapy had oxygen cylinders that indicated zero (0) readings on the oxygen gauge. The arrows indicated readings on the red zone of the gauge. When the Licensed Practical Nurse (LPN) was asked regarding confirmation of the oxygen bottle gauge reading, the LPN stated that they needed to be changed and proceeded to acquire more oxygen bottles. A Certified Nursing Assistant (CNA) who was assisting to feed one of the residents was asked to verify the resident's oxygen gauge reading and stated, "She's on PRN (as needed) orders for oxygen." At 12:06, all five oxygen cylinders were changed and checked by the LPN. Medical record reviews on the same day revealed the physician's orders [REDACTED]. -Resident #32 - ordered 11/06/11, "O2 (oxygen) at 2-4 L/min (liters per minute) per nasal cannula prn (as needed) to maintain O2 sat (saturation) > (greater than) 90%." -Resident #33 - ordered 3/19/12, "O2 at 2 L/min via nasal cannula, continuous." -Resident #34 - ordered 3/15/12, "O2 at 2L/min via nasal cannula, continuous to keep O2 sat > 90%." -Resident #35 - ordered 4/19/12, "O2 at 2L/min via nasal cannula, continuous to maintain SPO2 (peripheral oxygen saturation) > 92%." -Resident #36 - ordered 11/15/11, "O2 at continuous 2 1/2 L/min via nasal cannula." Further interview with another LPN on 5/17/12 at 2:43 PM revealed, "I check my gauges when they get up to go to therapy, when they get back from therapy and when the resident tells me." Another CNA was interviewed on 5/18/12 at 9:20 AM. It revealed, "I check O2 when I get them up. I always check it when I do care with them. " The DON acknowledged on the same day that oxygen cylinders, "needed constant monitoring. I don't know if there is a policy on specific times but 3-4 hours depending on liter flow and when they are leaving the units." A document review on 5/18/12 on Respiratory Policies and Procedures, Subject: Equipment Rounds General, original 3/06 indicated, "Purpose: To verify operational status of oxygen cylinders throughout the facility. Procedures: 1. Per schedule identified by the facility, personnel shall verify oxygen equipment, which is in use, and check accuracy of FIO2 (fraction of inspired oxygen) and/or liter flow." Resident #38 On 5/18/12 at 10:37 AM, unsampled resident #38 was observed sitting up in bed watching television. The resident was not receiving oxygen. An oxygen concentrator was observed at the residents' bedside. The concentrator was not turned on and the oxygen tubing was laying over the top of concentrator. The resident was not observed to be having any signs of respiratory difficulty. The resident was interviewed regarding his oxygen use. The resident indicated the concentrator had been set up for his use yesterday(5/17/12) and he had used the oxygen four hours only at that time. The resident went on to explain the oxygen caused his mouth and nose to dry up. The resident indicated the treatment would be improved if there was a humidifier on the concentrator. Review of this residents medical record revealed documented evidence showing a signed physician's orders [REDACTED]. The order was dated 5/1/12. Resident #39 On 5/18/12 at 8:52 AM, unsampled resident #39 was observed laying in bed watching television. The resident was not receiving oxygen. An oxygen concentrator was observed at the residents' bedside. The concentrator was not turned on and the oxygen tubing was laying over the concentrator. The resident was not showing any signs of respiratory difficulty. During an interview this resident indicated he did not use the oxygen all the time because it made his mouth and nose dry. The resident indicated he had requested a humidifier but it had not been delivered. Review of this residents medical record revealed documented evidence showing a signed physician's orders [REDACTED]. Resident #5 On 5/18/12 at 8:49 AM, Resident #5 was observed in the day room sitting in a Geri-chair in a reclined supine position. The resident was not receiving oxygen. There was not an oxygen concentrator or cylinder observed near the resident or in the day room. The resident was not exhibiting any breathing abnormalities. Review of this residents medical record revealed a signed physician's orders [REDACTED]. The order was dated 5/1/12. Resident #18 Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The medical record of resident #18 was reviewed on the morning of 5/15/12. The record contained a signed physicians order to schedule the resident for an appointment with a specialty clinic. The order was noted by nursing staff on 2/11/12. The record also contained a communication form dated 2/11/12, confirming the request to schedule the resident for a follow up visit with the specialty clinic. The form was signed by nursing staff and dated 2/11/12. The medical record contained a consultation form dated 2/16/12 at 10:00 AM. The three page consultation form revealed the resident was referred to a physician for specialty care. The physician documented that this patient was not known to him and there was no lab work indicating the resident needed specialty treatment. The physician recommended the resident follow up with the original specialty care provider. An addendum to the consultation revealed the physician had spoken with staff at this facility and determined that resident #18 was a patient at a specific specialty clinic. The physician indicated the resident needed to return to that specialty clinic for follow up. The medical record of Resident #18 lacked evidence that the resident had returned to the specialty clinic for care. The ADON (Assistant Director of Nursing) was interviewed regarding the physician order [REDACTED]. In the afternoon of 5/16/12, the social worker was interviewed regarding the scheduling of the follow up appointment at the specialty clinic. The social worker indicated that all appointments are scheduled by the facility scheduler. On the morning of 5/17/12, the employee responsible for scheduling appointments confirmed that Resident #18 did not have and had not been scheduled for an appointment for follow up care at the specialty clinic. Resident #30 Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/16/12 at 8:56 AM, Resident #30's medication pass was observed. The label for [MEDICATION NAME] revealed 100 U/ml (units per milliters) administer 0.90 cc (cubic centimeters) at bedtime. On 5/16/12 during medication pass, the LPN (Employee #16) double checked the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The LPN identified the resident and explained the medications, then administered a SQ injection of [MEDICATION NAME]. Review of Resident #30's medical record revealed a physician's orders [REDACTED]. The physician's orders [REDACTED]. Start [MEDICATION NAME] 48 units SQ BID (twice daily) Q12H (every 12 hours)." On 5/16/12 at 2:30 PM, the LPN verbalized, "the insulin ([MEDICATION NAME]) is correct on the MAR." The facility's policy entitled, "Medication Management Guidelines Program" (Revised 9/2011). Security and Safety Guidelines indicated: "13..........medications with an order change or patient/resident room change are returned to the pharmacy for re-labeling." Resident #31 The facility's policy entitled, The facility's policy entitled, "Medication Management Guidelines Program" (Revised 9/2011) indicated: "Step III: Administering the Medication Pass: 10. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member administers eye medications as follows:E. Tilt the patient's/resident's head back.I. Steady your hand holding the dispenser against the patient's/resident's forehead, and instill the drop inside the lower lid.L. ..........and gently wipe off excess medication with a clean tissue form the inside to the outside." Resident #31, an unsampled resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/16/12 during medication pass observation, Resident #31 had a physician's orders [REDACTED]. Resident #31 was observed seated in the wheelchair. The resident's head was slightly titled to the left with left hand resting against the face palm side up. During the medication pass, the LPN (Employee #15) stooped front left side of the wheelchair and told the Resident #31 to look up. The LPN pulled the left lower lid down and instilled one drop in the resident's eye, then wiped the excess medication from the resident's eye outside to inside with a tissue. The LPN instilled one drop into the resident's right eye, then wiped the excess medication from the resident's eye outside to inside with a tissue. The LPN did not use the proper technique for the administration of Resident #31's eye drops according to the facility's policy. Resident #8 Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's physician orders [REDACTED]. There was no documentation of parameters to hold the medication. Documentation on Resident #8's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The original physician orders [REDACTED]. There was no parameter indicated to hold the medication due to a low P rate. Resident #8's MAR for March 2012, documented the [MEDICATION NAME] was held a total of 18 times during the month of March 2012. Resident #8's MAR for March 2012, indicated the [MEDICATION NAME] was held on the following days due to a low BP, but the BP was greater than 100/60: - 3/01/12 0800 (8:00 am),BP 101/60, P 58; - 3/02/12 1500 (3:00 pm), BP 105/58, P 62; - 3/09/12 2000 (8:00 pm), BP 106/61, P 59; - 3/15/12 0800, BP 107/67, P 60; - 3/18/12 1500, BP 100/62, P 64 Resident #8's MAR for March 2012, indicated the [MEDICATION NAME] was held on the following days due to a low pulse rate: - 3/29/12 0800, P 56, - 3/30/12 0800, P 56. There was no documented evidence the physician was notified that Resident #8's [MEDICATION NAME] was held so frequently through the month of March 2012. Resident #8's MAR for April 2012, documented the [MEDICATION NAME] was held a total of 11 times during the month of April 2012. Resident #8's MAR for April 2012, indicated the [MEDICATION NAME] was held on the following days due to a low BP, but the BP was greater than 100/60: - 4/03/12 0800 , 106/62, P 58; - 4/17/12 0800, BP 104/61, P 67; Resident # 8's MAR for April 2012, indicated the [MEDICATION NAME] was held on the following days due to a low pulse rate: - 4/05/12 0800, P 56, - 4/12/12 0800, P 56, - 4/26/12 0800, P 59. There was no documented evidence the physician was notified that Resident #8's [MEDICATION NAME] was held so frequently through the month of April 2012. On 5/16/12 at 2:30 PM, interviewed two LPN's (Licensed Practical Nurse) (Employee #34 and Employee #35) regarding the procedure for holding a resident's BP medication. Both employees verbalized it was nursing judgement as to when to hold the medication depending if the BP or heart rate were low. Employee #34 indicated if the systolic BP was less than 110, the medication should be held. Both employees were asked if the physician should be notified when a resident's BP medication was held frequently. They both responded "Probably". On 5/16/12 at 2:45 PM, the Unit Manager (UM) indicated there should be parameters ordered by the doctor to hold the BP medication. On 5/17/12, the UM obtained clarification orders regarding the parameters to hold Resident #8's BP medications. The orders indicated to hold the [MEDICATION NAME] if the systolic BP was less than 90, or the heart rate was less than 60.

Based on record review, interview and policy review, the facility failed to ensure necessary care and services were provided to attain and maintain the highest practicable well-being for 6 of 17 sampled Residents (Residents #1, #8, #11, #12, #13 and #17). Findings include: Resident #1 Resident #1 was initially admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1's clinical record included a physician's order dated 6/17/11 for " ... Occult blood x 3" Resident #1's clinical record included two occult blood test results, dated 6/21/11 and 6/22/11. The clinical record lacked results of a third occult blood test. Resident #8 Resident #8 was initially admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #8's clinical record included a BM (bowel movement) Record on which each of three shifts (10:00 PM - 6:00 AM, 6:00 AM - 2:00 PM and 2:00 PM - 10:00 PM) were to document the resident's bowel activity. Resident #8's clinical record lacked documentation of bowel activity for 51 of 63 shifts from 6/10/11 through 6/30/11. The record lacked information indicating the resident had or had not moved his bowels for 51 of 63 shifts. Resident #8's clinical record included a physician's order dated 6/30/11, which indicated "1) [MEDICATION NAME] 500 mg (milligrams) orally three times a day for seven days for diarrhea; 2) [MEDICATION NAME] 1 tablet orally every four hours PRN (as needed (for diarrhea)) ... " Resident #12 Resident #12 was initially admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #12's clinical record included a standing order to " ... Record BM (bowel movement) Q shift (every shift)." The BM Record for the month of June, 2011 revealed Resident #12 did not have a bowel movement from 2:00 PM on 6/25/11 through 10:00 PM on 6/28/11. Resident #12's clinical record included a physician's order for " ... mineral oil enema (over the counter) rectally PRN (as needed for) constipation." A 6/29/11 6:00 AM physician's order indicated, "May give [MEDICATION NAME] suppository one per rectum if no BM in three days." An in-service form signed by all staff who attended the training indicated, " ... CNA's (certified nursing assistants) need to accordingly document in the BM book and or in POC (plan of care), Nurse's (sic) need to review the BM book and or access POC to see when your residents last had a BM, if the resident is capable of telling you then you should ask. ... CNA's in addition to a daily report to the nurse of the residents BM status, if you have worked with the same resident for 2-3 consecutive days and has noticed that a resident has not had a BM you should stress this as an urgent concern to the Nurse. Nurses when it is brought to your attention you need to go an assess your resident listening for bowel sounds in all four quadrants, check to see if the abdomen is distended, soft, hard, and notify the physician of your findings, suggest a KUB (abdominal x-ray), suppository, stool softeners, laxatives and administer as prescribed." (Previous paragraph copied verbatim from facility's policy.) The facility's policy, Nursing Assessment of the Older Adult ... revealed, " ... 2. Constipation - bowel frequency less than three times per week - left untreated may lead to fecal impaction and bowel obstruction A. Risk factors: Decreased physical activity, decreased abdominal musculature, ... ignoring urge, inadequate fiber/bulk/fluid intake, prolonged bedrest ..." Resident #13 Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. 1. The Bowel Movement Record dated June 2011, documented Resident #13 had a bowel movement on 6/14/11 and 6/15/11. Nurse's notes dated 6/16/11, documented the resident did not have a bowel movement for 3 days, 3 tablespoons of Magnesia given. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s order for Magnesia, 3 tablespoons or any other laxative order until a physician's order was received 6/30/11. On 7/7/11 at 11:25 AM, Employee #1 and Employee #2 were not able to locate a physician's order for Magnesia. On 7/7/11 at 11:30 AM, Employee #2 stated you need to have a physician's order for a medication and the resident had been given a medication with out a physician's order. 2. The MAR indicated [REDACTED]'s orders for [MEDICATION NAME] sulfate (iron) 325 milligram (mg) orally three times a day, [MEDICATION NAME] (stool softener) 100 mg orally twice a day hold for loose stools, [MEDICATION NAME] Controlled-Release Tablets ([MEDICATION NAME] narcotic pain killer) 15 mg orally twice a day. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The Bowel Movement Record dated June 2011, documented Resident #13 did not have a bowel movement on the 2-10 shift on 6/15/11, and no bowel movement on 6/16/11, 6/17/11, 6/18/11. The MAR indicated [REDACTED]. On 7/7/11 at 11:20 AM, Employee #1 stated the resident should have received some medication after 3 days with no bowel movement. The employee was not able to locate documentation the resident had received a laxative. On 7/7/11 at 11:25 AM, Employee #2 stated if a resident did not have a bowel movement in 3 days a bowel assessment needed to be done. The nurse needed to check for abdominal distention, nausea, vomiting and the physician should be contacted and orders obtained. Employee #2 was not able to locate documentation in the medical record to indicate a bowel assessment was completed on Resident #13 after 3 days with no bowel movement or the physician had been contacted. On 7/7/11 Employee #1 stated the concern regarding constipation was you don't want the resident to get an obstruction. Resident #11 Resident #11 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 6/30/11, a physician's order was received to change the resident's [MEDICATION NAME] (a blood thinner) to 8 mg orally every night for the [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. The documentation indicated the resident received [MEDICATION NAME] 7 mg. On 7/7/11 at 8:45 AM, Employee #5 compared the physician's orders with the current MAR. The employee stated it did not appear the physician's orders were followed. On 7/7/11 at 9:00 AM, Employee #4 reviewed the documentation regarding the [MEDICATION NAME] and the bubble pack which contained [MEDICATION NAME] 3 mg tablets. Employee #4 was asked if the physician's order was followed. The Employee stated "No." On 7/7/11 at 11:10 AM, the Director of Nursing (DON) stated she had spoken with the Pharmacy regarding Resident #11's [MEDICATION NAME] orders. The DON stated the Pharmacy advised her they had not received [MEDICATION NAME] orders after 6/23/11. The DON was not able to provide documentation to show the staff obtained the proper [MEDICATION NAME] dosage from the in-house medication system. The facility's policy entitled, Physician Orders-Medication Treatment dated 3/06, documented the licensed nursing staff will provide patients/residents with medications and treatments as ordered by his/her physician. Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on 3/24/11 and 6/22/11. The resident was discharged from the facility on 6/25/11, with [DIAGNOSES REDACTED]. 1. The Bowel Record dated June 22, 2011 through 6/25/11 lacked documentation Resident #17's bowel movements were monitored every shift on 6/23/11 and 6/24/11. 2. On 3/28/11, a physician's order was received for Resident #17 to have a competency evaluation. Nurse's notes dated 4/1/11, documented Resident #17's physician had contacted the Psychiatrist and indicated he would be in on Monday. On 5/26/11, a physician's order was received for Resident #17 to have a Psychiatrist evaluation and social service guardianship. A consultation report dated 6/6/11, documented Resident #17 did not have the capacity to make any type of decision. On 6/7/11, a physician's progress note dated 6/7/11, documented at this time Resident #17 did not have the capacity to make any decisions. Recommend guardianship. On 6/23/11, a Social Service progress note dated 6/23/11, documented a referral was made to the public Guardian's office. On 7/8/11 at 9:00 AM, the Nurse Practitioner (NP) seeing Resident #17 stated the competency evaluation would take a couple days to arrange and should have been done earlier. On 7/8/11 at 9:30 AM, the Director of Social Service and a facility Social Worker stated they had no idea why the competency evaluation was not completed until 6/6/11. The Director of Social Service verbalized they were waiting for the Psychiatrist to evaluate the resident for competency and then would contact the Public Guardian's office with the referral. 3. The Wound Care Progress notes dated 6/23/11 documented the skin and wound assessment had been completed by the nurse and new physician's orders were obtained. The Wound treatment and Progress note dated 6/23/11 documented the resident's wound care was done per the physician's order. On 6/24/11 the wound care notes documented the Nurse Practitioner saw maggots in the residents wound. Wound care was completed and a new treatment order was received for the wound. The Wound Care Progress note dated 6/25/11 documented Resident #17 had refused wound care. The medical record contained a physician's order dated 6/25/11, to transfer Resident #17 to an acute care hospital to treat his face wound. Nurse's Notes dated 6/25/11, documented Resident #17 was transferred to the hospital per the physician's orders for a Legal 2000 (Application, Certification and Medical Clearance for Emergency Admission of an Allegedly Mental Ill Person to a Mental Health Facility). Social Service notes dated 6/27/11 documented Resident #17 was placed on a Legal 2000 on 6/25/11, for refusal of care. The medical record lacked documentation a physician's order had been received for Resident #17 to be placed on a Legal 2000 and transferred to an acute care hospital. The Quality of Care Review notes for Resident #17 were blank with no documentation on the form except the resident's name and room number. On 7/8/11 at 9:00 AM, the NP on Resident #17's case stated the resident had always refused care at the facility. The NP stated the resident was not a risk of hurting himself or others. The NP stated he did not give an order to Legal 200 Resident #17. On 7/8/11 at 9:30 AM, the Director of Social Service and a facility Social Worker stated they were not aware of the facility meeting and discussing with the resident why he refused care. On 7/8/11 at 10:00 AM, a Registered Nurse (RN) stated he saw the Legal 2000 form filled out for Resident #17 from the day shift nurse. The RN completed a new Legal 2000 form to send the resident out because the nurse who transferred the resident was required to sign the document. The RN assumed the day nurse had obtained the order for the Legal 2000. The RN verbalized he did not review the medical record to see if a physician's order had been obtained to Legal 2000 the resident. The RN stated there was no physician's order for the Legal 2000. During the interview on 7/8/11, the RN verbalized another nurse had spoken to the physician and obtained an order to transfer the resident to a different hospital because the initial hospital would not accept the resident. The RN stated the physician called and gave a verbal order to Legal 2000 Resident #17 and transfer him to another hospital. The RN stated the physician's order to Legal 2000 Resident #17 and send him to another hospital had not been written. On 7/8/11 at 10:15 AM, the Director of Nursing (DON) stated there should have been a telephone order written for the Legal 2000 and a copy of the Legal 2000 document. On 7/8/11, the facility was not able to provide a copy of the physician's order to transfer the resident out as a Legal 2000 or the completed Legal 2000 document. On 7/8/11 at 10:25 AM, Employee #6 stated telephone orders should be written because it was an physician's order. "It's protocol", we need to write the orders. The facility's policy entitled, Discharge/transfer dated 3/06, and revised 2/08 and 6/08, documented in order to process an involuntary discharge the facility will obtain a physician's order for the discharge. Documentation from the acute care hospital's Emergency Department dated 6/25/11, documented Resident #17 was put on a medical hold by an RN at the care facility because they said that he was refusing wound treatment and would not leave the dressing on. The facility's policy entitled Refusal of Treatment dated 3/06, documented the nursing staff will recognize the residents right to refuse a treatment or procedure ordered by the physician. When a patient/resident refuses a treatment/procedure ordered by a physician, staff shall coordinate a care conference with patient/resident and physician to discuss the positive and negative consequences of refusal and an alternate treatment or procedure, if indicated. Document all discussions in the Nursing Progress notes and if the patient/resident continues to refuse treatment, contact the Legal Department for appropriate release. CPT #NV 721

Based on observation, interview, record review and policy review, the facility failed to provide care and services for residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 6 of 27 sampled residents (Resident #4, #5, #6, #10, #19, and #27). Findings include: Resident #27 1. On [DATE], the facility readmitted Resident #27 with [DIAGNOSES REDACTED]. Documentation in Resident #27's file showed a physician ordered [MEDICATION NAME] time (PT) and international normalized ratio (INR) labs throughout the resident's stay from [DATE] through [DATE]. The physician adjusted the resident's [MEDICATION NAME] dose from 5 milligrams to 4 milligrams during this period. On [DATE], the facility sent the resident out for evaluation for respiratory distress, acute febrile illness, and hypoxemia. 2. On [DATE], the facility readmitted Resident #27. Physician #2 indicated "...we will continue [MEDICATION NAME]. We will monitor PT/INR with goal INR between 2 and 3..." in the history and physical. Documentation in Resident #27's file showed Physician #2 ordered PT/INR labs throughout the resident's stay from [DATE] through [DATE]. The resident's INR ranged between 1.7 and 2.7 during this time. Physician #2 adjusted the resident's [MEDICATION NAME] dose from 3 milligrams to 4 milligrams and then 5 milligrams during this period. On [DATE], the facility sent the resident out for evaluation for shortness of breath and nausea. 3. On [DATE], the facility readmitted Resident #27 with [DIAGNOSES REDACTED]. Physician #2 indicated treatment would include continuation of resident #27's transfer medications, which included [MEDICATION NAME]. The resident also received Aspirin 81 milligrams daily. The resident's admission skin check indicated ecchymosis on the bilateral upper extremities and right inner thigh. On [DATE], Physician #2 ordered [MEDICATION NAME] 5 milligrams daily. The medication administration record showed Resident #27 received [MEDICATION NAME] 5 milligrams daily from [DATE] through [DATE]. Resident #27's admission orders [REDACTED]. None of the telephone/written orders in the resident's file contained orders for PT/INR. On [DATE], Physician #2 ordered several labs, none of these labs were for PT/INR. On [DATE], Physician #2 ordered labs, none of these labs were for PT/INR. On [DATE], the facility sent the resident out for evaluation due to a head wound and significant bleeding from a fall. The resident was on [MEDICAL TREATMENT] during the stay. The labs drawn at [MEDICAL TREATMENT] for the month of March were obtained and none included PT/INR. Documentation from the hospital showed Resident #27's initial INR was 6.2, and the resident received at least 6 units of fresh frozen plasma for coagulopathy. The resident returned to the facility on [DATE] and expired on [DATE]. Physician #2 wrote a short stay summary and indicated [MEDICATION NAME] toxicity as one of the readmitting diagnoses. On [DATE] at 4:00 PM, Physician #2 indicated the resident's [MEDICATION NAME] therapy should have been monitored with PT/INR labs during the stay from [DATE] through [DATE]. Physician #2 indicated the nurse did not write the order; nurses were supposed to call Physician #2. Physician #2 indicated standing orders of Monday lab draws were supposed to be followed. On [DATE] at 8:15 AM, Employee #13 indicated Physician #2 never ordered PT//INR labs or the labs would have been documented. Employee #13 signed the orders off at 10:25 PM on [DATE]. Employee #13 faxed the orders at 2:10 AM on [DATE]. Physician #2 never signed the orders until [DATE]. According to the facility's nursing policy, physician orders-telephone and verbal dated [DATE], Employee #13 followed the correct procedures outlined. On [DATE] in the morning, Employee #4 indicated the facility did not have standing orders for [MEDICATION NAME] therapy or a [MEDICATION NAME] therapy policy, just a [MEDICATION NAME] Flow Record form; where upon, nurses documented the date, dose, PT/INR results, physician notification, new dose ordered, date of the next PT/INR, and their initials. Resident #27's file lacked documentation any nurse ever attempted to contact a physician regarding the lack of PT/INR lab orders for [MEDICATION NAME] monitoring. Employee #4 indicated nurses carried out physician's orders [REDACTED]. On [DATE] in the afternoon, Pharmacist #1 indicated there was an expectation of PT/INR labs during a resident's [MEDICATION NAME] therapy, but Pharmacist #1 indicated he would not endorse a recommendation for lab draws until the second month's drug regimen review for a resident. Pharmacist #1 reviewed Resident #27's drug regimen on [DATE], 11 days after readmission. Resident #4 On [DATE] in the late morning, observation revealed Resident #4 sitting in a wheelchair watching television alone in a room. A complaint of a strong odor of unknown origin prompted the observation. After investigation, a concentrated odor was discovered emanating from the left calf area of Resident #4. The calf was wrapped with kerlix and dated [DATE]. Resident #4's file and treatment administration record were reviewed. The physician's orders [REDACTED]. The 30 days expired [DATE]. Employee #14 indicated the wound was foul-smelling and the original physician's orders [REDACTED]. The order included a normal saline wash, the use of [MEDICATION NAME] Cream, and a kerlix wrap daily and as needed. Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. The history and physical examination [REDACTED]. The physician's orders [REDACTED]." There was no documented evidence of a physician's orders [REDACTED]. The Wound Progress Notes indicated the following: [DATE]: "Admission skin check complete by RN (registered nurse) charge & wound [MEDICAL CONDITION] L (left) lower leg...Per Public Guardian Resident has hx (history) of refusing wound care to L lower leg." [DATE]: "(Name of Dr.) returned paged. Wound nurse spoke (with) (name of Dr.) regarding resident wound [MEDICAL CONDITION] L lower leg (with) maggots. New order obtained & noted antibiotics po (by mouth)." [DATE]: "Resident refused tx (treatment) x (times) 2. Resident let this nurse clean only." [DATE]: "Resident refused cleaning of L lower leg. Resident non-compliant (with) treatment refuses cleaning & dsg (dressing). Call social worker to talk (with) him. L lower leg has order - will cont (continue) to try (with) treatment." [DATE]: "Refuses tx to L lower leg" [DATE]: "Tx nurse found (night shift reported) maggots in L lower leg - cleaned and will monitor - about less than 20." The Wound Treatment & Progress Record indicated Resident #4 refused treatment on [DATE], [DATE], and [DATE]. The Nurse's Notes indicated the following: [DATE]: "Wound care done by wound nurse..." [DATE]: "Res (resident) refused shower offered x3 we will cont to monitor." [DATE]: "Res refused shower." [DATE]: "Was refusing meds (medications) at first attempt but he finally took it when offered again." [DATE]: "Res shower refused also shave refused. Offered x2. Res stated "tomorrow" we will cont to monitor." [DATE]: "Res refused shower he states it's too windy. Offered to change his clothes refused. He stated 'Tomorrow'." [DATE]: "Resident refused all meds don't want it." [DATE] "...Dr. (doctor) in to see res. This nurse reported to M.D. (Medical Doctor) left lower leg (with) maggots...Psychiatrist to eval res reported to M.D. res resistive (with) meds and today refused. We will cont to monitor." On [DATE] in the morning during tour, the Unit Manager indicated Resident #4 was non-compliant with showers, and would only take a shower on Fridays by one particular CNA (Certified Nursing Assistant). On [DATE] at 4:00 PM, a telephone interview was conducted with the resident's physician (Physician #2). The physician indicated he had been made aware of the maggots by the nurses on [DATE] and [DATE]; however, he stated he was not made aware the resident was refusing medications, showers, and treatment of [REDACTED]. On [DATE] in the morning, a telephone interview was conducted with the Public Guardian Representative for Resident #4. The Public Guardian Representative indicated she had a long discussion on [DATE] with the Social Worker that Resident #4 had a history of [REDACTED]. The Representative further indicated the facility did not notify her regarding the resident's refusal of treatment to the wound after admission to the facility, refusal of showers, and changes to the wound, including the maggots. The facility's policy and procedure regarding Refusal of Treatment (,[DATE]) indicated, "POLICY: The nursing staff will recognize the patient's/resident's right to refuse a treatment or procedure ordered by the physician and according to the Facility Practice Guidelines. PROCEDURES: 1. When a patient/resident refuses a treatment/procedure ordered by a physician, staff shall coordinate a care conference with patient/resident and physician to discuss the positive and negative consequences of refusal and an alternate treatment or procedure, if indicated." Resident #5 Resident #5 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The Care Plan (Problem: Risk for injury/falling - start date: [DATE]) did not indicate the use of a tab alarm and a mat on the floor as indicated by the Physician's recapitulation (recap) effective [DATE]: "Fall Precautions: Tab Alarm, Landing Mat." On [DATE], [DATE], [DATE], and [DATE], there was no evidence of a mat on the floor by the bed. On [DATE] and [DATE] it was verified by the nurse that a landing floor mat was not used for Resident #5. Resident #10 Resident #10 was originally admitted to the facility on [DATE], and last readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #10 had a gastrostomy ([DEVICE]) for feeding and was on hospice care. Resident #10's physician orders [REDACTED]." Resident #10's nurse's notes dated [DATE] at 1900 (7:00 PM), documented "Noted with congested and spitting up large amount phlem (sic). Suction at 1800 (6:00 PM). Suction 2nd time at 1830 (6:30 PM). Noted with dark flecks. Also approx (approximately) 150 cc (cubic centimeters) dk (dark) brown emesis. Feeding being held. Dr. (name) notified of resident emesis." Resident #10's medical record included a Diagnostic Imaging Report dated [DATE] which documented "There is diffuse large and small bowel loop dilatation consistent with significant ileus...The gastrostomy tube is over the gastric region. There is moderate gastric air distention." The CNA (Certified Nursing Assistant) ADL (Activity of Daily Living) forms for the month of October, 2010, documented Resident #10 had bowel movements on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. There was no documented evidence Resident #10 had bowel movements on any other days throughout the month. There was no documented evidence Resident #10 received any additional laxative or enema to stimulate the resident's bowels. The CNA (Certified Nursing Assistant) ADL forms for the month of November, 2010, documented Resident #10 had bowel movements on ,[DATE] and ,[DATE]. There was no documented evidence Resident #10 had bowel movements on any other days prior to ,[DATE], when the resident developed the ileus. There was no documented evidence Resident #10 received any additional laxative or enema to stimulate the resident's bowels. Resident #19 Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident went out to [MEDICAL TREATMENT] three times a week. The physician's orders [REDACTED]." Resident #19's care plan identified the problem of Resident #19's LUA (left upper arm) AV (Arterial Venous) fistula and resident attended [MEDICAL TREATMENT] on M-W-F. The goal for this problem was to keep Resident #19 free from infection over the next 90 days. The approach listed for this included "5. Check LUA (left upper arm) fistula daily for bruit, s/s (signs/symptoms) of infection, and bleeding. LN (Licensed nurse) to check VS (Vital signs), and assess M-W-F after [MEDICAL TREATMENT] for s/s of infection, bleeding, pain, etc. Report abnormalities to MD promptly." There was no documented evidence in the medical record or on the Medication Administration Record (MAR) that Resident #19's bruit was checked upon return from [MEDICAL TREATMENT] for April or May, 2011. On [DATE] in the morning, the medication nurse indicated a communication form was sent with Resident #19 when he went for [MEDICAL TREATMENT], and should be returned with the resident. The communication form included information regarding the resident prior to [MEDICAL TREATMENT], such as medications administered, labs drawn, vital signs and any other pertinent information. The communication form also included information from the [MEDICAL TREATMENT] center such as the resident's weights before and after [MEDICAL TREATMENT], vital signs, total fluid removed and any pertinent information during the procedure. There was no documented evidence of any completed communication forms for Resident #19's [MEDICAL TREATMENT] for April or May, 2011, in the medical record or MAR. On [DATE] in the morning, the Unit Manager was unable to locate any completed [MEDICAL TREATMENT] communication forms. Resident #6 Resident #6 was initially admitted to the facility on [DATE],with [DIAGNOSES REDACTED]. On [DATE], the resident was transferred to the hospital for evaluation for placement of a gastrostomy tube ([DEVICE]). Resident #6 returned to the facility on [DATE] with the following tube feeding order: [MEDICATION NAME] 1.2 at 70 cc (cubic centimeters) per hour and NPO (nothing by mouth), with water flushes 250 cc every six hours. On [DATE] this order was changed to: [MEDICATION NAME] 1.2 at 85 cc per hour x 20 hours and 150 cc water flushes every six hours; on at 10:00 AM and off at 6:00 AM. On [DATE] at 3:50 PM, Resident #6's feeding tube was observed to be running at 70 cc per hour, and the enteral formula bottle was nearly full. A nurse on the 200 Hall (Employee #11) reported she started the feeding at 2:00 PM, and indicated the schedules of most tube feedings in the facility were "off at 10:00 AM and on at 2:00 PM." The employee acknowledged the order had not been clarified and changed to reflect the facility's normal practice. The employee further acknowledged the feeding rate should have been set at 85 cc per hour. Review of Resident #6's record revealed that both the tube feeding order and the water flush order were written in the same space on the Medication Administration Record (MAR). There were initials showing the tube feedings were started each day, but there was no indication the water flushes were given. The charge nurse (Employee #12) confirmed the enteral feeding order and the water flush order should have been separated out on the MAR, with specific administration times listed for each order, so that nurses could initial the MAR whenever the flushes were given.