Every finding on record at Oasis Nursing & Rehab of Green Valley

Based on interview, record review, and document review, the facility failed to ensure 1 of 50 residents (Resident 205) with a Full Code status was provided basic life support (BLS) after being found unresponsive. Facility staff did not initiate cardiopulmonary resuscitation (CPR) as required. This deficient practice deprived the R205 of required life saving measures, specifically CPR, which may have potentially increased the resident's chance of recovery and survival. Findings include:Resident 205 (R205) admitted on [DATE] with diagnoses including acute respiratory failure.A nursing progress note dated [DATE], documented at approximately 8:15 AM when the Registered Nurse (RN) was doing rounds the patient was found unresponsive to verbal and tactile stimuli, no heartbeat noted, no pulse, no respirations, pupils were fixed and fully dilated. The RN called and made the house supervisor aware of the incident. A Physician order dated [DATE] documented an order of Full Code status for R205.A review of R205's Nevada Provider Order for Life-Sustaining Treatment (NV POLST) dated [DATE] revealed a checkmark in the designated box Attempt Resuscitation (CPR -cardiopulmonary resuscitation) under section A. This section applied when the patient had no pulse and was not breathing. The form documented when not in cardiopulmonary arrest to follow orders in Section B and C. Section B documented the Full Treatment which indicated to prolong life by all medically effective means. R205's Code status form dated [DATE] documented to administer cardiopulmonary resuscitation (CPR).The medical record showed the last documented blood pressure was recorded on [DATE] at 4:37 PM, with a reading of 100/76, taken manually by the Registered Nurse, (RN).The medical record lacked documented evidence the following actions were performed upon discovery of R205 as unresponsive:Vital signs were taken.CPR was initiated or administered.Change in condition protocols were completed.A comprehensive nursing assessment was conducted.Emergency Medical Services (EMS) were contacted.The physician instructed the RN supervisor to discontinue CPR efforts or cancel paramedic response.An official pronouncement of death was determined.On [DATE] at 3:55 PM, the Clinical Resource Nurse and Interim Director of Nursing (DON) confirmed that no automated external defibrillator (AED) summary report sheet had been completed for resident R205 on [DATE]. The Clinical Resource Nurse verbalized the expectation for the RN was to complete thorough documentation, including vital signs, the resident's condition, and criteria indicating whether R205 met or did not meet requirements for interventions. Documentation should have reflected whether CPR was initiated, as well as the time and details of the physician notification. The Clinical Resource Nurse reported while RNs were permitted to pronounce death under the facility's standing order, an order to pronounce must be obtained from the physician.On [DATE] at 2:48 PM, a Licensed Practical Nurse 3, (LPN3), confirmed when a resident was unresponsive an assessment would be conducted and CPR would begin because delaying CPR could cause further life changing effects. The LPN clarified basic life support (BLS) certification directed staff not to delay the first compression when an individual was found unresponsive and represented the residents' life changing choices. The LPN indicated the automated external defibrillator (AED) should be present. On [DATE] at 2:54 PM, Registered Nurse 4 (RN4), CPR must be conducted when a resident was full-code status and denying or not performing CPR on a resident is against a resident's choices and BLS certification standards. The RN acknowledged the AED should have been nearby for use if needed. On [DATE] at 2:58 PM, RN5, indicated when a resident was discovered unresponsive the nurse would conduct an assessment and start CPR for a full-code resident. The RN indicated AED was present in case it needed to be utilized. RN5 BLS standards were to not delay the first compression when an individual was found unresponsive. On [DATE] at 3:05 PM, LPN1, verbalized once a resident was found unresponsive an assessment would be conducted, call for help and start CPR for a full-code resident and AED should be present. The LPN confirmed BLS standards were not to delay the first compressions.On [DATE] at 5:18 PM, LPN4 reported being asked by RN1, to assist because it appeared R205 had passed. Upon arrival, LPN4 agreed with RN1's assessment that R205 was deceased and CPR was not initiated, instead the house supervisor was contacted. LPN4 verbalized their observations were the reason CPR was not initiated. The LPN acknowledged CPR may not have been performed because the resident appeared deceased . The LPN did not obtain vital signs and could not recall whether the assigned RN obtained vital signs. The LPN clarified it was not within the LPN's scope of practice to determine death or decide not to initiate CPR.On [DATE] at 5:24 PM, LPN4 confirmed the assigned RN did not initiate CPR but instead contacted the LPN for assistance. The LPN indicated they were unfamiliar with the facility's AED and did not recall anyone bringing it to the scene. The LPN indicated the backboard was not placed, the crash cart was not brought to the room, and an AED was not present. The LPN confirmed BLS certification directed staff not to delay the first compression when an individual was found unresponsive, but the LPN deferred the decision to the two RNs present. On [DATE] at 7:23 AM, a phone interview was conducted with a physician regarding the incident when R205 was found unresponsive. The physician reported receiving a call from the RN supervisor at approximately 8:15 PM concerning R205's condition. According to the physician, the RN supervisor indicated R205's vital signs had been assessed a few hours prior and were within normal limits, with no concerns noted throughout the shift. The RN supervisor reported that when the assigned RN discovered R205, the resident's eyes were fixed, there were no respirations or heartbeat, and rigor was present. The physician indicated that the RN supervisor reported CPR was not initiated because R205's physical presentation indicated that resuscitation would not be feasible. The physician clarified during the call R205 was designated as full code and CPR should have been initiated if any signs suggested the possibility of resuscitation. The physician verbalized the RN supervisor reported CPR would not be conducted due to the observations of R205s current condition, therefore, 911 was not contacted. On [DATE] at 8:10 AM, the Clinical Resource Nurse and Interim DON confirmed there was no AED summary report pertaining to R205s code in the medical record. Additional review of R205s medical record lacked documented evidence of the following:The death record dated [DATE] at 8:15 PM, had no check mark by the pronouncement of death for R205.R205 was pronounced deceased or expired prior to contacting the cremation service provider for pick up.On [DATE] at 12:42 PM, the Minimum Data Set (MDS) coordinator confirmed the facility has not conducted any mock code drills during their 17 years of employment. The MDS coordinator indicated mock code drills would be beneficial in improving staff competency in responding to code situations, especially because code events did not occur often within the facility. On [DATE] at 12:43 PM, the Infection Preventionist (IP), reported not having participated in any mock code drills during the two years of their employment. The IP acknowledged if the facility would conduct mock code drills it would definitely benefit the staff understanding on how to respond in a code. On [DATE] at 8:34 AM, the Clinical Resource Nurse and Interim DON indicated employees received disciplinary action when there was a failure to comply with or there was a violation of the facility's employee handbook. The Clinical Resource Nurse Interim DON reported the following disciplinary actions related to the event under review:Certified Nursing Assistant 1 (CNA1): disciplined for failure to document required information in a timely manner.RN1: disciplined for failure to take action during an emergency, documentation and for not following facility policy during a code.RN2: disciplined for failure to document and not following facility policy during a code.RN 3: disciplined for failure to communicate and document events related to the incident.LPN4: disciplined for failure to take action during an emergency, document, communicate, and not following facility policy during a code. On [DATE] at 9:34 AM, the Medical Director explained when a resident exhibited a change of condition or a decline, residents were typically sent to the hospital. The Medical Director indicated it was rare for staff to encounter a code situation, making it understandable that staff may not have felt comfortable performing codes; therefore, mock code drills were needed to ensure staff competency. The Medical Director indicated standing orders, such as the RN may pronounce, must be removed for all residents, noting that that is not right.The Medical Director indicated when a resident was found unresponsive, the following actions were required:Vital signs must be obtained;A full assessment must be documented;CPR must be initiated;EMS must be contacted, and the resident sent to the hospital, even if there were signs suggesting the resident may have been deceased .On [DATE] at 10:54 AM, the Director of Staff Development (DSD) reported not conducting mock code drills and not providing training on the AED and the crash cart.Educational materials were requested from the Clinical Resource Nurse and Interim Director of Nursing, regarding staff training on how to respond during a code, emergency preparedness, and mock code procedures for staff prior to R205s code blue event on [DATE] at 1:00 PM, [DATE] at 9:00 AM, and on [DATE] at 8:15 AM. No documented evidence of the educational materials or training was provided.A review of the facility's document titled Identification of Potentially Affected Residents - Full Code Status Verification Audit, with a review date of [DATE], showed R205 was listed as having expired on [DATE] with a code status of CPR. The documentation lacked notes indicating CPR had been initiated for R205.The facility's policy Staff Roles During Code Blue (undated) documented the following code blue procedure standards:Call for assistance, announce a Code Blue, and direct personnel to call 911 immediately.Retrieve the crash cart and automated external defibrillator (AED).Verify the residents' code status. If a Do Not Resuscitate (DNR) order is on file, immediately halt compressions and cancel emergency medical services (EMS).Initiate and maintain continuous record-keeping throughout the event.The facility's policy titled Death of a Resident, Documenting revised [DATE], documented appropriate documentation shall be made in the clinical record concerning the death of a resident and all information pertaining to the resident's death must be recorded in the nurses' notes.The facility's policy titled Discharging a Resident to the Mortuary revised [DATE] indicated a resident must be declared legally dead in accordance with state law, either by direct or indirect pronouncement by a licensed physician.Complaint 3071967

Based on record review, interview, and document review, the facility failed to ensure nursing staff followed physician orders for medication hold parameters, reassessed a resident with critically abnormal vital signs, implemented appropriate interventions for hypotension, and notified the attending physician of significant changes in condition for 1 of 50 sampled residents (Resident 206). This deficient practice contributed to a delay in necessary medical intervention for Resident R206, who was later found unresponsive, leading to activation of emergency response measures and subsequent death.Findings included:Resident 206 (R206) was originally admitted on [DATE] with diagnoses including atrial fibrillation, hypotension, supraventricular tachycardia, hypertension, and the presence of a cardiac pacemaker. R206 was hospitalized on [DATE] for a heart rate of 170 beats per minute (BPM) and discharged back to the facility on [DATE] with diagnoses including atrial fibrillation with rapid ventricular response, pleural effusion, and lactic acidosis.A nursing progress note entered on [DATE] at 12:04 PM (over an hour after the resident was found unresponsive) documented that earlier in the morning, R206 had a critically low blood pressure of 57/30 millimeters of Mercury (mmHg) and a heart rate of 138 BPM. This late entry documented R206 had been responsive to verbal and tactile stimuli, was assisted to a wheelchair, and took morning medications without difficulty. The medical record lacked any evidence the severely abnormal blood pressure and heart rate was assessed at the time of discovery, implemented appropriate interventions to address the hypotension, or notified the attending physician of these critical findings prior to the resident's collapse.In the same 12:04 PM nursing progress note, the nurse documented at 11:00 AM, subsequent to the unaddressed hypotensive episode, R206 was found unresponsive in the dining room, and at 11:02 AM, a Code Blue was initiated, 911 was called, and cardiopulmonary resuscitation (CPR) was initiated. The note revealed emergency medical services arrived and later pronounced R206 deceased .The Medication Administration Record (MAR) for [DATE], indicated the antihypertensive medications Metoprolol 25 milligrams (mg) extended release (ER) and Furosemide 40 mg, both of which can lower blood pressure, were administered on [DATE] at 8:00 AM despite the critical hypotensive episode that occurred at 6:00 AM, and based on a documented extemporaneous blood pressure of 100/61 mmHg obtained by a Certified Nursing Assistant at 5:20 AM.Vital sign records showed that the last blood pressure obtained before the morning medication pass on [DATE] was taken at 5:20 AM, with a reading of 100/61 mmHg. The medical record lacked evidence that blood pressure was reassessed immediately before administering Metoprolol and Furosemide at 8:00 AM, despite the presence of hold parameters.Physician orders dated [DATE] revealed Metoprolol Succinate ER 25 mg was ordered once daily for hypertension with instructions to hold the dose if systolic blood pressure was below 110 mmHg or heart rate below 60. Furosemide 40 mg was ordered daily for acute pulmonary edema with instructions to hold the dose if systolic blood pressure was below 100 mmHg.On [DATE] at 11:45 AM, a Licensed Practical Nurse (LPN1) explained if a patient had parameters for holding a medication based on the vital signs, the nurse administering the medication should verify the vital signs prior to the administration of the medication and not rely on the vital signs obtained by another nurse or certified nursing assistant (CNA). If the vital signs were found to be critically abnormal, the attending physician should be notified immediately to request orders to treat the situation.On [DATE] at 1:04 PM, LPN2 reported having found R206 unresponsive in the dining room and initiated CPR. LPN2 could not recall whether the critically abnormal vital signs (BP 57/30 mmHg, HR 138 BPM) were reassessed or whether the attending physician was notified.On [DATE] at 1:30 PM, the Director of Nursing (DON) confirmed the physician order to hold the medication Metoprolol was not followed, as the nurse administered it despite a systolic blood pressure of 100 mmHg. DON could not produce evidence that a case review, an incident report, or an investigation following a significant medication error was conducted.On [DATE] at 9:15 AM, the Medical Director, who was also 206's attending physician, stated it was expected nurses follow hold parameters for any medication, including blood pressure medication. The Medical Director indicated that the holding parameters were intended to prevent adverse effects of the medication. The Medical Director indicated the blood pressure medication, and the diuretic should have been placed on hold after R206 experienced hypotension and tachycardia. The physician confirmed that a blood pressure of 53/30 mmHg and a heart rate of 138 BPM constituted an emergency and warranted immediate action, including reassessment of vital signs, notification of the physician, medical intervention, and transfer to the emergency department if necessary.On [DATE] at 9:15 AM, the Medical Director, who also served as R 206's attending physician, stated nurses were expected to follow all medication hold parameters, including those for antihypertensive and diuretic medications. The physician explained hold parameters were in place to prevent adverse medication effects and emphasized both the blood pressure medication and the diuretic should have been held after R206 exhibited hypotension and tachycardia. The Medical Director further confirmed that a blood pressure of 53/30 mmHg and a heart rate of 138 BPM represent a medical emergency and require immediate action, including reassessment of vital signs, notification of the attending physician, implementation of appropriate medical interventions, and transfer to the emergency department if indicated.The facility policy titled Blood Pressure, effective [DATE], stated that any abnormal blood pressure reading should be reported to the nurse immediately.The facility policy titled Change in a Resident's Condition or Status, revised in February 2021, documented the nurse was required to notify the resident's attending physician or the on call physician when there had been a significant change in the resident's physical/emotional/mental condition. The policy defined significant change of condition as a major decline or improvement in the resident's status that would not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions. The policy stated that, prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather pertinent information for the provider, including information prompted by the Interact SBAR Communication Form.The facility policy titled Medication Administration, revised and dated [DATE], documented that medication and treatment errors and undesirable effects should be immediately reported to the Director of Nursing or the designee, and the attending physician, documented with details in the medical record, and described in a full incident report.

Based on interview, record review and document review, the facility failed to use the correct technique when applying a mechanical lift sling for 1 of 50 residents (Resident 102) who requires care in pairs. This deficient practice constituted past non-compliance, existing from 05/22/2026 to 05/26/2026. The facility returned to compliance on 05/26/2026 prior to the start of the current survey, after implementing corrective actions including staff termination, disciplinary actions, removal of incorrect sling sizes, and 100% staff competency retraining. This deficient practice had the potential to increase serious body harm and risk of injury to the resident. Findngs include:Resident 102, (R102) was readmitted on [DATE] with diagnoses including fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing. On 07/16/2026 at 8:39 AM, an observation of R102s room revealed the mechanical lift sling was not present. On 07/16/2026 at 9:05 AM, an inspection of the 100-unit linen closet revealed a box containing various individually bagged slings. Each bag contained a sling of a different color. A Certified Nursing Assistant (CNA) identified as CNA3 indicated all pink slings had been removed from the unit entirely.An Alert Note dated 05/22/2026 documented that staff were called to room [ROOM NUMBER]B where the resident was found lying face down on the floor. The RN Supervisor was notified, and 911 was contacted for transport to the emergency room. Staff did not reposition the resident and waited for paramedics to arrive. The resident was documented as alert and oriented to person and place (AOx2) and complained of pain to the neck and forehead. Paramedics arrived and transported the resident to the emergency room. The resident's emergency contact was notified, and the physician was informed of the fall.A nursing note dated 05/22/2026 documented staff were called to the resident's room where the resident was found to have sustained a fall. The resident was awake and lying on his left side in a prone position on the carpet, with no signs or symptoms of respiratory distress observed. Emergency services (911) were called STAT. At 11:20 AM, paramedics transported the resident to the emergency room via stretcher. At 12:00 PM, the primary care provider was notified of the incident.A nursing note dated 05/25/2026 documented the resident was readmitted to the facility with a femoral neck fracture, a bunny boot applied to the left foot, +2 pitting edema to the left foot, a right scalp abrasion, and blanchable redness to the bilateral heels and buttocks.A hospital Discharge summary dated [DATE] documented R102 presented to the hospital after experiencing a fall with head impact during a transfer from bed to wheelchair using a mechanical lift. Hospital imaging (X ray) showed an acute, mildly impacted left femoral neck fracture. The discharge summary indicated that, based on these findings, there were concerns for a left femoral neck fracture requiring surgical intervention.The care plan dated 04/17/2026 documented R102 required Cares in Pairs for all ADL assistance. The care plan goal documented R102 needs would be met and cares would be provided safely. Documented interventions included direct care staff to pair two staff members together when providing cares and to place a Cares in Pairs sign above the resident's door to ensure staff are alerted to this requirement.On 07/16/2026 at 8:00 AM, three Certified Nursing Assistants (CNAs), identified as CNA5, CNA6, and CNA7, were observed transferring a resident from a shower bed to a standard bed. The transfer was performed using a three person assist. One CNA was positioned at the back of the resident utilizing the pull handle, while the remaining two CNAs were positioned on each side of the resident. The lift contained four hooks, two supporting the upper body and two supporting the lower body. The resident was lifted from the shower bed and lowered onto the bed without noted issues.On 07/16/2026 at 8:34 AM, R102 was interviewed regarding the 05/22/206 fall incident. R102 recalled that on the day of the incident, CNA4 entered the room to assist R102 out of bed for a scheduled appointment using a mechanical lift, CNA4 was alone and not accompanied by a second CNA. R102 verbalized that the care required two CNAs to assist. R102 indicated CNA3 later entered the room to assist with the transfer. R102 verbalized that once lifted and no longer positioned over the bed, the mechanical lift began to move unexpectedly. R102 indicated CNA4 attempted to stop the movement, at which point R102 fell forward out of the sling, landing headfirst. R102 reported the sling remained attached to the mechanical lift during the fall.On 07/16/2026 at 8:41 AM, CNA5 reported awareness of R102's fall that occurred approximately one and a half months prior during a mechanical lift transfer. CNA5, CNA6, and CNA7 were not on duty at the time of the incident; however, the CNAs became aware of the details through in service training provided afterward. CNA6 explained the facility had multiple sling sizes available for use for the mechanical lift however, CNA6 indicated the staff were uncertain whether the correct sling size had been utilized for R102 at the time of the fall.On 07/16/2026 at 8:50 AM, the Infection Preventionist (IP) indicated the facility's policy indicates that two CNAs must be present to do a transfer of a resident with a mechanical lift.On 07/16/2026 at 9:00 AM, CNA3 indicated upon entering the room to assist CNA4 with a mechanical lift transfer, CNA3 identified CNA4 had already placed the sling underneath R102. CNA3 reported R102 was designated as a care in pairs resident and CNA4 should have had an additional CNA present prior to initiating care. CNA3 clarified their role was to guide the mechanical lift while CNA4 was responsible for guiding R102 into the wheelchair. CNA3 verbalized that once R102 was positioned in the mechanical lift, R102 jerked, causing R102 to fall out of the sling. CNA3 acknowledged that at the time of the incident involving R102's fall, it was identified that the incorrect sling had been attached to the mechanical lift and the sling used was too small for R102. CNA3 confirmed that following the incident, the Director of Nursing (DON) instructed CNA3 and CNA4 to demonstrate and reenact the events of the mechanical lift transfer and both were sent home for the remainder of the day. CNA3 indicated that both CNAs received written disciplinary action and additional training before being placed back on the work schedule.On 07/16/2026 at 9:49 AM, the DON provided the employee record for CNA4, which indicated CNA4 had received a final disciplinary action and was ultimately terminated for various unrelated concerns. The DON also provided information showing CNA3 received a written disciplinary action related to the mechanical lift transfer incident involving Resident R102. CNA3 and CNA4 were provided with additional training and competency testing immediately following the incident before returning to the work schedule.On 07/16/2026 at 8:47 AM, CNA8 indicated that during a mechanical lift transfer, facility policy required two CNAs to be present one to guide the mechanical lift and the other to guide the resident. CNA8 clarified that a sling could not be applied without two CNAs present and that transferring a resident alone is against facility policy. CNA8 indicated the facility conducted training a few months prior regarding proper mechanical lift techniques, sling sizing, and the importance of two staff mechanical lift transfers.On 07/16/2026 at 9:07 AM, CNA3 indicated mechanical lift transfers required two CNAs at all times due to safety considerations for both the resident and staff. CNA3 reported additional training was conducted following Resident R102's fall during a mechanical lift transfer. The training addressed proper use of various sling sizes, correct mechanical lift transfer techniques, and the importance of having two staff members present during all mechanical lift transfers. CNA3 explained that the facility utilizes multiple sling sizes that are color coded: pink for extra small, purple for small, green for medium, and blue for large. CNA3 indicated the slings were stored in linen closets, and CNAs were responsible for selecting the appropriate sling size for each resident during transfers.On 07/16/2026 at 9:28 AM, CNA9 indicated mechanical lift transfers required two CNAs at all times. CNA9 clarified that one CNA was responsible for guiding the mechanical lift, while the other CNA guided the residents to ensure safety. CNA9 reported the facility conducted training for all CNAs and nurses on mechanical lift protocols and procedures following Resident R102's fall incident. CNA9 indicated the facility provided various sling sizes for resident transfers and CNAs were required to select the correct sling size before applying it to ensure resident safety and prevent falls. CNA9 explained monthly meetings were held covering various facility topics, with mechanical lift transfers being a primary focus. CNA9 indicated the DON routinely checked mechanical lift practices to ensure staff compliance with proper protocols.On 07/16/2026 at 9:48 AM, the DON provided mechanical lift training records dated May 22, 2026. The records indicated that weekly huddles were conducted on various topics, with falls and mechanical lift procedures identified as priority areas. The DON verbalized a CNA had recently been suspended for attempting to transfer a resident alone. The DON clarified that licensed nurses were responsible for ensuring CNAs performed mechanical lift transfers with two staff members present; failure to follow this protocol must be reported, resulting in a final write up and suspension for the CNA involved. The DON indicated the facility conducted a quarterly CNA skills fair, which included Nevada scope competency testing and skills assessments for CNAs.On 07/16/2026 at 10:18 AM, LPN7 indicated mechanical lift transfers required two staff members at all times. LPN7 reported the facility provided various sling sizes to ensure proper and safe transfers. LPN7 clarified using an incorrect sling size may result in a resident slipping out of the sling, causing serious injury, which was why two CNAs are required to verify the correct sling size prior to application. LPN7 indicated that mechanical lift transfer procedures and fall prevention topics are addressed during every staff huddle. LPN7 confirmed CNAs are required to demonstrate weekly competency in mechanical lift transfers as part of ongoing facility safety practices. The facility policy titled Lifting Machine, Using a Mechanical, revised July 2017, indicated that at least two nursing assistants were required to safely move a resident with a mechanical lift. It further directed staff to measure the resident for the proper sling size and to visually verify that the sling was not too large or too small before use.Complaint 3033147

Based on interview, record review, and document review, the facility failed to ensure an accurate process was implemented for receiving, documenting, and safeguarding resident personal funds for 1 of 50 sampled residents (Resident 56). The deficient practice had the potential to result in inaccurate accounting of resident funds, financial loss, and the inability to verify funds entrusted to the facility. Findings include: Resident 56 (R56) was admitted [DATE], with diagnoses including aphasia following cerebral infarction, unspecified protein calorie malnutrition, and abnormalities of gait and mobility.Document review revealed the facility reported R56 questioned the balance of the resident's trust account and they should have had $200 in the trust account. The facility's investigation revealed the resident had provided two $100 dollar bills to the receptionist for deposit into the trust account but received a receipt reflecting only $100. The Business Office subsequently located the two $100 bills attached to a receipt which reflected $100.On 07/14/2026 at 10:35 AM, R56 explained the missing money situation was cleared up by the facility when R56 reported they should have had a $200 balance. R56 did not want to discuss all details of the incident.On 07/14/2026 at 12:16 PM, the Business Office Manager, explained when residents brought in cash, a two-part receipt should have been written, one part should have gone to the resident, the second part should have been paperclipped with the cash placed in a bag, in sealed envelope so the funds were separated by resident and taken to the business office.On 07/15/2026 at 12:23 PM, the Director of Social Services, reported R56 asked about their account balance/statement. The Business Office found $200 with a receipt attached that reflected only a $100 deposit. The Director of Social Services confirmed it was a receipt problem, R56 deposited $200 but was given a receipt of $100 in error. The Director of Social Services reported the confusion may have happened because the facility changed from clipping money together to instead placing the money in an envelope. This change may have affected the process. The Director of Social Services confirmed the facility did not provide the residents with an accurate receipt and the funds were found clipped together with an inaccurate receipt. The Director of Social Services did not know how the process should have worked. This surveyor was referred to speak to reception regarding the correct process that should have been followed. On 07/15/2026 at 12:37 PM, a facility receptionist explained when residents turned in funds, a receipt was to be written, the money placed in an envelope and given to Business Office to deposit the funds. The receptionist indicated R56 reported the funds were missing and they were found in the Business Office. The receptionist acknowledged did not know what went wrong with the process of depositing funds for R56.On 07/16/2026 at 8:16 AM, the Assistance Business Office Manager reported the Receptionist should have separated R56's funds correctly in an envelope when received to avoid confusion with R56's funds. The receptionist explained envelopes were implemented again after the incident with R56 and acknowledged it was R56's right to have an accurate account of their funds and access to them.A facility document titled Procedure for Receipt of Payments and Resident Funds, (undated), documented all cash or other forms of payment received for a resident must be verified immediately upon receipt. A pre-numbered three-part receipt must be completed immediately upon receipt of funds. The receipt must include the date, resident name, and amount received. FRI 3018499

Based on observations, interviews, record review, and document review, the facility failed to develop a comprehensive, person-centered care plan addressing fall risks for 1 of 50 sampled residents (Resident 172). This deficient practice had the potential to result in residents not receiving care and services in accordance with their assessed needs.Findings include:Resident 172 (R172) was admitted to the facility on [DATE] with diagnoses including cerebral palsy (unspecified), protein-calorie malnutrition, type 2 diabetes mellitus with unspecified complications, immunodeficiency due to underlying conditions, chronic bronchitis, and unsteadiness on feet.The facility could not provide updated care plan for R172 following a fall which occurred on 06/26/2026. The facility could not provide documentation fall interventions were reviewed and adjusted to address the resident's ongoing fall risk and prevent future occurrences.A nursing progress note dated 07/01/2026 documented a STAT Nurse to the Gazebo was called. Upon arrival, R172 was found lying on the concrete floor under the gazebo, in front of wheelchair near the water cooler. R172 had a large bump on her right forehead, a skin tear on right elbow, and a small abrasion on right knee. The paramedics arrived, evaluated, and transported to an acute care hospital.On 07/16/2026 at 4:27 PM, a licensed practical nurse (LPN) Supervisor, acknowledged R172 should have had a care plan review completed following R172's fall on 06/29/2026. The LPN Supervisor explained the resident's care plan should have been revised within one week of the fall date to ensure appropriate follow up and ongoing monitoring.The LPN Supervisor confirmed there were no updated interventions in the resident's care plan on file for R172 dated around 06/29/2026. LPN Supervisor acknowledged documentation should have been completed and/or updated on the date of the fall.On 07/17/2026 at 3:20 PM, the Director of Nursing (DON) indicated when R172 experienced a fall, the interdisciplinary team (IDT) met, and the care plan should have been revised the same day. The DON acknowledged the care plan should have addressed the appropriate interventions and safety measures to prevent the R172 from falling. The DON verbalized staff members, including CNAs and nurses, were expected to consistently follow the care plan.The facility policy titled Care Plan, Comprehensive Person-Centered revised March 2022, the interdisciplinary team (IDT), in conjunction with the resident, and family or legal representative, develops and implements comprehensive, person-centered care plan for each resident. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implemented in revision to the plan of care.

Based on interview, record review, and document review the facility failed to ensure the medical records were complete and accurate for 1 of 5 sampled residents (Resident 3). The deficient practice had the potential for residents not to receive timely interventions needed and for the facility missing the opportunity to identify care issues.Findings include:Resident 3 (R3) was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, chronic obstructive pulmonary disease, and benign prostatic hyperplasia without lower urinary tract symptoms.A Physician order dated 07/27/2026 documented Metoprolol Succinate extended release (ER) tablet 25 milligrams (MG) give one tablet by mouth one time a day related to essential hypertension. Hold for systolic blood pressure (SBP) 110 and below and/or heart rate below 60 beats per minute.The Medication Administration Record (MAR) documented on 08/20/2026 at 9:00 AM R3's blood pressure (BP) was 82/60 and Metoprolol Succinate ER tablet was administered below the prescribed parameters.On 08/20/2026 at 10:05 AM, R3's Licensed Practical Nurse (LPN) explained for residents that were either hyper or hypotensive the nurse would follow the physician orders and prescribed parameters for medication administration. The nurse would continue to monitor the resident and contact the physician if there were no changes.On 08/20/2026 at 10:08AM, the LPN reviewed R3's medical record and acknowledged had documented Metoprolol Succinate ER as administered at 9:00AM with R3's BP documented at 82/60. The LPN explained being unaware of the documented BP and stated a Certified Nurse Assistant (CNA) had obtained the BP earlier in the morning. The LPN further explained the medication, despite being signed as administered, had not yet been administered due to R3 having been combative and R3 was generally hypertensive. The LPN explained R3's BP should have been obtained prior to medication administration.On 08/20/2026 in the morning, the Regional Clinical Director verbalized the LPN was removed from floor assignment.The facility policy titled Charting and Documentation, revised 07/2017, documented documentation in the medical record would be complete and accurate.The facility policy titled Documentation of Medication Administration, revised 11/2022, documented administration of medication was documented immediately after it was given.

Based on observation and interview, the facility failed to ensure staff stored their beverages in a designated area. This deficient practice had the potential to cause cross contamination and compromise infection control practices within the facility.Findings include:On 07/14/2026 at 9:56 AM, a single-use disposable water bottle was observed stored on the hallway handrail located by the nurse's station next to the Licensed Practical Nurse 5's, (LPN5) medication cart.On 07/14/2026 at 9:57 AM, LPN5 clarified the water bottle belonged to them and acknowledged it should have been stored in the employees refrigerator rather than on the hallway handrail.On 07/14/2026 at 11:12 AM, LPN6 confirmed storing an employee drink on the hallway handrail presents an infection control concern and confirmed employee beverages were required to be kept in the employee breakroom refrigerator, which was instructed upon hire. On 07/14/2026 at 11:16 AM, a Certified Nursing Assistant 2, (CNA2), reported employee drinks were not permitted on the nursing floor due to infection control concerns and clarified that beverages must be stored in the employee breakroom refrigerator, not on a hallway handrail.On 07/17/2026 at 1:20 PM, the Administrator indicated the facility did not have a policy regarding designated employee food storage. The Administrator clarified employees were educated upon hire that personal food and drinks were to be stored in the employee breakroom refrigerator or in employee lockers.On 07/17/2026 at 2:00 PM, the Clinical Resource Nurse and Interim Director of Nursing indicated the facility did have a policy for designated employee food storage, but employees were aware food and drinks were stored in the employee breakroom not in resident care areas, handrails or nurses' stations.

Based on interview, record review, and document review, the facility failed to ensure an allegation of abuse was reported to the State Agency within the required timeframe for 1 of 3 sampled residents (Resident 1). The deficient practice had the potential to delay reporting of alleged abuse and place the resident at risk for continued abuse. Findings include:Resident 1 (R1) was admitted [DATE], with diagnosis including osteomyelitis, cognitive communication deficit, and dementia unspecified severity without behavioral disturbance, psychotic mood disturbance, mood disturbance and anxiety.On 04/13/2026 at 8:55 AM, R1 reported that a Certified Nursing Assistant (CNA) became upset because they played with the sheets and did not pay attention to the CNA. R1 indicated the CNA was rude and hit them in the right eye, on purpose, not by accident. R1 explained their eye hurt that day and no one checked R1's eye. R1 reported the incident to the nurse that same day and did not get a response from them. R1 explained they did not feel safe at the facility because what happened could happen again.A facility Abuse/Neglect/Exploitation/Sexual-In-Nature/Theft Questionnaire dated 04/04/2026, documented R1 reported to a Registered Nurse (RN), when they were being changed a CNA was moving R1 around and R1 did not like it. R1 raised their hands and when the CNA turned around R1 pushed the CNA. The CNA hit R1 in the eye. The RN called the Acting Director of Nursing to report the incident. R1 had a red mark below the eye and redness to the eye.A Skin assessment dated [DATE] completed by a Registered Nurse documented an abnormal finding including a red mark under the right eye and redness to his right eye.A Resident Investigation Form (Staff-Statement) dated 04/07/2026, with an attached written statement, signed by a Licensed Practical Nurse (LPN), documented R1 reported they did not want anything to do with the CNA because the CNA had hit them in the face in the morning and held their hands down and punched them in the right eye.Physician Notes dated 04/07/2026, documented the physician was called for redness around the right eye. R1 was hit but could not recall the incident. A handwritten statement dated 04/07/2026, signed by a CNA, documented R1 reported their eye was hurting and R1 was assaulted. R1 reported a CNA held hands and hit them in the face.The medical record documented R1 reported the alleged abuse to multiple staff members. The facility lacked documented evidence the allegation of abuse was reported to the State Agency.The medical record lacked documented evidence the allegation of abuse had been reported to the Administrator until 04/07/2026.A Summary of Investigation and Findings dated 04/09/2026, signed by the Administrator, documented based on a thorough investigation, the abuse allegation was not substantiated.On 04/13/2026 at 10:08 AM, the Administrator explained the abuse allegation received from R1 on 04/04/2026 was reported to them on 04/07/2026. The Administrator reported if an allegation of abuse was identified over the weekend, the Administrator would be contacted by staff for the purpose of reporting allegations of abuse. The Administrator explained they usually would have reported the abuse allegation to the State Agency and then investigated. The Administrator decided to investigate first and based on the conclusion of the investigation which included R1's known behavior, difficulty with staff of certain races and history of making allegations and made the decision not to report the allegation of abuse to the State Agency. The Administrator acknowledged facility's policy documented all allegations of resident abuse were to be reported to local, state and federal agencies, however explained this particular allegation of abuse was not reportable because the allegation of abuse was unsubstantiated. On 04/13/2026 at 11:01 AM, the Acting Director of Nursing, acknowledged facility's policy documented that all reports of resident abuse were reported to local, state and federal agencies as required and thoroughly investigated by facility management. The Acting Director of Nursing stated the Administrator upon receiving allegations of abuse, was responsible for determining what actions, if any, were needed for the protection of the residents. The Acting Director of Nursing acknowledged the Registered Nurse who received the allegation of abuse on 04/04/2026 did not notify the Administrator as required. Allegations of abuse were to be reported within 2 hours to 24 hours.On 04/13/2026 at 1:10 PM, a Registered Nurse (RN) explained in the event of an altercation between residents the RN immediately separated the residents, assessed residents to determine if injury or medical attention was needed. The RN reported abuse to the supervisor, the Director of nursing, physician and police. The RN explained abuse had to be reported immediately. The Director of Social Services indicated the facility had reported incidents, including abuse allegations, to the State Agency. The Director of Social Services explained R1 had a history of making stories and false allegations. The Director of Social Services reported receiving guidance about 10 years ago indicating that when a resident's history of false allegations was documented in the care plan, abuse allegations did not need to be reported to the State Agency and could instead be handled internally as a soft file investigation. If an allegation could be resolved internally, it was not considered reportable. When asked about the facility's policy on reporting abuse and required timelines, the Director of Social Services was unable to identify any policy requiring all abuse allegations to be reported to the State Agency. A Facility Reporting and Investigation Checklist documented, Protect the Resident! You must call 911 immediately (not later than 2 hours after the allegation was made) if you witness or suspect a crime or if the events that caused the allegation are sexual in nature (inappropriate touching i.e.) or involved abuse, neglect or results in serious bodily injury. Contact the Administrator, Director of Nurses, or Director of Social Services immediately. A facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating revised September 2022, documented all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property were reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations were documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must have been reported immediately to the Administrator and to other officials according to state law. Immediately was defined as within two hours of an allegation involving abuse or resulting in serious bodily injury or within 24 hours of an allegation that did not involve abuse or result in serious bodily injury.Complaint 2978946

Based on interview, record review, and document review, the facility failed to ensure each resident or resident's guardian provided signed evidence of informed consent prior to the administration of a psychoactive medication, for 2 of 51 sampled residents (Residents 169 and 191). The deficient practice had the potential to put residents at risk of using psychoactive medication without understanding the risks and benefits of the medication. Findings include: 1) Resident 169 (R169) was admitted on [DATE] with diagnoses including bipolar disorder. The medical record indicated a guardian had been appointed to make medical decisions for R169. A Physician Order dated 09/20/2024 indicated to give Quetiapine (an antipsychotic medication) 25 milligrams (mg) at bedtime for mood related to bipolar disorder. A review of the September 2025 Medication Administration Record (MAR) revealed the resident had taken Quetiapine every evening of the month. The MAR indicated R169 was monitored for potential side effects of the Quetiapine which included constipation, blurred vision, and confusion. The record lacked documented evidence the guardian had given informed consent for the use of the Quetiapine. On 09/26/2025 at 1:25 PM, the Director of Nursing (DON) indicated nurses were supposed to contact the resident or resident's representative/family, explain the risks and benefits of using the medication, and then if consent was given, document the consent in the record. The DON verified R169s record lacked documented evidence informed consent had been obtained for R169 to use Quetiapine starting on 09/20/2024. The DON verbalized consent should have been obtained prior to starting the medication. 2) Resident 191 (R191) was admitted on [DATE], and readmitted on [DATE], with diagnoses including dementia, depression disorder, polyneuropathy, chronic obstructive pulmonary disease and bipolar disorder. A Physician Order dated 09/05/2025 documented Sertraline Hydrochloride (HCI) oral tablet 50 milligrams (mg), give one tablet by mouth one time a day for verbalization of sadness related to major depressive disorder. R191's medical record lacked documented evidence an informed consent was obtained prior to the first administration of Sertraline (HCI) on 09/05/2025. On 09/26/2025 at 12:33 PM, a Licensed Practical Nurse (LPN), stated if the resident was alert, the resident was asked to sign the medication consent form. If the resident was not alert, the resident's representative or family member was contacted to obtain consent. On 09/26/ 2025 at 1:18 PM, the Director of Nursing (DON), indicated before a resident could be placed on a psychotropic medication, a consent must be obtained and a consent form signed. If the resident was not alert, the family or legal representative needed to sign the consent form. If the resident was alert, the resident was required to sign the consent. The DON indicated psychotropic medications should not be administered without a signed consent form. The facility policy titled Psychotropic Medication Use, effective 07/2022, documented residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with residents/representatives the risks related to not taking the medication as well as appropriate alternatives.

Based on interview, record review and document review, the facility failed to ensure a significant change in status assessment was completed for a hospice resident for 1 of 3 closed record sampled residents (Resident 200). The deficient practice had the potential for a hospice plan of care to not be generated. Findings include: Resident 200 (R200) was admitted on [DATE], with diagnoses including Alzheimer's dementia and protein-calorie malnutrition. An Alert Note dated 07/24/2025 revealed R200 was admitted to hospice care.The medical record lacked documented evidence that a significant change in status assessment was completed when R200 was admitted to the hospice program on 07/24/2025.On 09/26/2025 at 8:20 AM, the Minimum Data Set (MDS) Coordinator reviewed R200's medical record and confirmed R200 was admitted to the facility on [DATE] and was enrolled into the hospice program on 07/24/2025. The MDS Coordinator acknowledged that a significant change in status assessment was not completed for R200 in accordance with resident assessment instrument (RAI) requirements.On 09/26/2025 at 8:30 AM, the MDS Coordinator explained the facility had 14 days to complete a significant change in status assessment from a resident's admission into hospice in accordance with the RAI manual and the assessment would then generate a hospice care plan. The MDS Coordinator explained that MDS staff were informed of changes in condition by 1) business office due to payor source change, 2) daily stand-up meetings and/or 3) direct communication by nursing staff. The MDS Coordinator indicated being newly hired in June 2025 and was not attending stand-up meetings in July 2025.On 09/26/2025 at 9:56 AM, the Director of Nursing (DON) confirmed there was no significant change in status assessment completed for R200 which was due 14 days after R200's enrollment into hospice for the purpose of generating a hospice care plan.On 09/26/2025 at 11:23 AM, the Medical Records Director confirmed R200 did not have a significant change in status assessment.The RAI Version 3.0 Manual dated October 2023, revealed a significant change in status assessment was required when a terminally ill patient enrolled into the hospice program. The assessment reference date must be within 14 days from the date of the hospice election. The significant change in status assessment must be performed regardless of whether an assessment was recently conducted on the resident.

Based on interview, record review and document review, the facility failed to develop a hospice care plan for 1 of 3 closed record sampled residents (Resident 200). The deficient practice had the potential to place the resident at risk for receiving inadequate hospice care.Findings include:Resident 200 (R200) was admitted on [DATE], with diagnoses including Alzheimer's dementia and protein-calorie malnutrition. An Alert Note dated 07/24/2025 revealed R200 was admitted to hospice care.The medical record lacked documented evidence that a hospice care plan was developed after R200 was admitted to hospice.On 09/26/2025 at 8:30 AM, the Minimum Date Set (MDS) Coordinator confirmed a hospice care plan was not developed when R200 enrolled into hospice on 07/24/2025 because the significant change in status assessment was not completed in accordance with resident assessment instrument (RAI) requirements.On 09/26/2025 at 9:56 AM, the Director of Nursing (DON) explained there was no significant change in status assessment completed within 14 days from R200's admission to hospice and may have been the reason a hospice care plan was not developed. The DON revealed hospice care plans typically included a goal focused on the resident's comfort and common interventions included pain management, following advanced directives and coordination between the facility and the hospice provider.The facility policy titled Comprehensive Person-Centered Care Plan, revised March 2022, documented a person-centered comprehensive care plan was developed within seven days of a significant change in status assessment. The interdisciplinary team would review and update the care plans after a significant change in the residents' condition.

Based on interview, record review and document review, the facility failed to ensure showers were provided as scheduled for a resident who required assistance with bathing for 1 of 51 sampled residents (Resident 202). The deficient practice had the potential to result in poor hygiene, increased risk for skin breakdown and negatively affect resident's dignity and psychosocial well-being. Findings include: Resident 202 (R202) was admitted to the facility on [DATE] and discharged on 06/01/2025 with diagnoses including Wernicke's encephalopathy, alcohol-induced chronic pancreatitis, and auditory hallucinations.The resident census documented R202 resided in room [ROOM NUMBER]B from 03/27/2025 to 05/08/2025, and room [ROOM NUMBER]B from 05/08/2025 to 06/01/2025.The facility document titled Preferred Shower Schedule for the 200-hall documented 203B was to receive showers on day shift Wednesday and Saturday. room [ROOM NUMBER]B was to receive showers on evening shift Tuesdays and Fridays.A Care Plan dated 04/07/2025 documented R202's had an Activities of Daily Living (ADL) self-care performance deficit related to encephalopathy, malnutrition, pancreatitis and pain with interventions including provide sponge bath when a full bath or shower could not be tolerated.The admission Minimum Data Set (MDS) dated [DATE] documented R202 required maximal assistance with shower/bathe self: the ability to bathe self, including washing, rinsing, and drying self (which excluded washing of back and hair).The facility ADL documentation for May 2025 documented a shower for R202 occurred on 05/13/2025 evening shift.On 09/25/2025 at 1:20 PM, Certified Nurse Assistant 4 (CNA4) explained when resident care was provided it was documented in the resident's chart. CNA4 explained that the documentation included all Activities of Daily Living (ADL) assistance provided including things such as showers, brief changes, and transfers.On 09/26/2025 at 9:29 AM, Certified Nurse Assistant 5 (CNA5), explained the residents had shower schedules and the bathing occurred twice a week. CNA5 explained completing skin shower sheets when showers were done, and the sheets were signed by a nurse. CNA5 explained the showers were documented in the resident's electronic record. On 09/26/2025 at 9:32 AM, a Registered Nurse (RN) reviewed R202's ADL bathing document for May 2025 and stated the lack of documentation looked like showers were not completed as assigned. On 09/26/2025 at 10:00 AM, the Director of Nursing (DON) confirmed showers for residents were scheduled twice a week along with staff completion of skin shower sheets. The DON explained the CNAs were to chart completion of bathing in the resident's electronic medical record.On 09/26/2025 at 11:54 AM, the DON reviewed R202's ADL documentation for May 2025 and confirmed one episode of bathing had been documented on 05/13/2025.On 09/26/2025 at 1:43 PM, the Medical Records Director was unable to locate additional May 2025 skin shower sheets for R202. The facility policy titled Activities of Daily Living , Supporting, revised March 2018, documented appropriate care and services would be provided for residents who were unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).Complaint 2287288

Based on observation, interview, record review and document review, the facility failed to ensure 1) a risk assessment for pressure ulcer development was completed and 2) a new skin impairment was identified and addressed for 1 of 51 sampled residents (Resident 12). The deficient practice had the potential to place the resident at risk for new or worsening pressure ulcers.Findings include:Resident 12 (R12) was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD), and acute osteomyelitis of ankle and foot.On 09/23/2025 at 9:55 AM, R12 was alert while seated in wheelchair. R12 recounted being hospitalized in July 2025 and a right foot wound was identified by emergency department (ED) staff which according to the resident was a new wound. R12 indicated being treated for osteomyelitis with intravenous (IV) antibiotics which was resumed upon returning to the facility.1) The facility policy titled Pressure Injury Risk Assessment, revised March 2020, documented to use a facility-approved risk assessment tool to identify a resident's risk for developing new or worsening pressure injuries. The assessment should be conducted as soon as possible after admission, weekly for the first four weeks, when there was a significant change in condition or as often as required based on the resident's condition. If a new skin alteration was identified, there must be documentation of physician notification.On 09/26/2025 at 1:37 PM, the Clinical Resource Nurse indicated the facility utilized the Braden skin assessment tool for determining a resident's risk for developing pressure injuries. The Braden assessment must be completed on admission, readmission and on a quarterly basis.A Braden assessment dated [DATE], revealed R12 was at risk for developing pressure ulcers due to being chairfast and limited mobility.The medical record lacked documented evidence staff completed a Braden assessment for R12 since 02/18/2023 (initial admission).On 09/26/2025 in the afternoon, the Clinical Resource Nurse and Medical Records Director confirmed there had been one Braden assessment completed for R12 since admission to the facility on [DATE].2) A Skin Assessment conducted on 07/02/2025, revealed R12's skin was intact with no skin impairments.A Nutrition Note dated 07/02/2025, revealed R12 had intact skin. A Nurse's Note dated 07/05/2025, revealed R12 was transferred to the hospital due to yellowish-green emesis.A Hospital Consultation Report dated 07/06/2025, documented R12's wounds which were present on admission included 1) a full thickness ulcer on right lateral foot with red granulation tissue and undermining, 2) a scabbed wound on the base on right fifth toe.A Hospital Discharge summary dated [DATE], revealed a wound consult for R12's right foot occurred due to wounds present on admission. Discharge medications included Meropenem 500 milligrams (mg) intravenously (IV) once daily for 10 days for osteomyelitis.A readmission Note dated 07/08/2025, revealed R12 returned to facility after being treated for nausea and vomiting and foot wound osteomyelitis.A Nurse's Note dated 07/08/2025, documented R12 arrived in a stretcher, dressing on right arm for IV and a right foot wound covered with dressing.A Skin/Wound Note dated 07/10/2025, revealed right lateral foot wound measured 15 millimeters (mm) length x 14 mm width x 3 mm depth with scant serosanguinous discharge. Wound bed with 50 percent (%) eschar and 50% granulation.On 09/26/2025 at 8:10 AM, a Treatment Nurse indicated being familiar with R12 since the nurse was treating R12's sacral wound which had resolved in June 2025. No new skin impairments were reported to the treatment team by the floor nurses regarding a right foot wound, but the treatment nurse recalled being informed R12 returned from the hospital with a right foot ulcer which was being treated with IV antibiotics.On 09/25/2025 at 3:32 PM, the Director of Nursing (DON) reviewed R12's medical record and indicated R12's right foot wound appeared to be facility-acquired not identified during the last weekly skin check on 07/02/2025. The DON indicated not performing skin checks in accordance with the facility's protocols, placed residents at risk for infection, development of new wounds, worsening of existing wounds and delay in appropriate interventions.The facility policy titles Prevention of Pressure Injuries, revised April 2020, documented skin checks were done within eight hours from admission, weekly and when there was a change in condition. Inspect the skin daily when performing care or activity. Document and report any changes in skin.

Based on observation, interview, record review and document review, the facility failed to ensure adequate supervision and a safe environment to prevent a resident with cognitive impairment from accessing and ingesting non-food items for 1 of 51 sampled residents (Resident 17). The deficient practice had the potential to result in choking, gastrointestinal upset or other adverse health outcomes. Findings include: 1) Resident 17 (R17) was admitted on [DATE] with diagnoses including unspecified dementia, hyperglycemia, and bipolar disorder. A Brief Interview for Mental Status (BIMS) evaluation dated 09/15/2025 documented a score of zero indicating R17 had severe cognitive impairment. A Progress Note dated 09/20/2025 documented R17 was taking sugar packets from the service area and was redirected. A Progress Note dated 09/22/2025 documented R17 was rummaging and taking sugar packets. When staff attempted to take sugar packets away, the resident started yelling R17 was given space, R17 eventually sat down, and staff were able to take some of the sugar packets. A Care Plan dated 10/14/2024 documented R17 was at risk for harm related to wandering throughout the unit and hoarding. On 09/25/2025 at 7:50 AM, R17 obtained multiple yellow packets of artificial sweetener from a drawer in the service area. A Licensed Practical Nurse (LPN) attempted to remove the packets from R17's hand and was unsuccessful. The LPN explained R17 liked to eat sugar and would sometimes eat the packet. On 09/25/2025 at 8:04 AM, R17 was pacing back and forth in the service area and placed an entire yellow packet of artificial sweetener into mouth and began to chew. The LPN approached R17 and attempted to get R17 to spit the packet out and R17 continued to chew, pushed past the nurse and began walking down the hall. The facility policy titled Behavioral Assessment, Intervention and Monitoring, revised March 2019, documented safety strategies would be implemented immediately if necessary to protect the resident and others from harm. 2) On 09/23/2025 at 8:10 AM, an inspection of the specialty care unit revealed two wooden cabinets with broken locks. The Director of Maintenance confirmed the cabinet locks were broken. Certified Nursing Assistant 1 (CNA1) confirmed the first cabinet contained approximately 200 sugar packets, 100 packets of artificial sweeteners, a box of breakfast syrup, and a variety of condiments such as catsup, mustard, cream of tartar and salt. The second cabinet contained three open bottles of liquid hand soap. On 09/23/2025 at 8:15 AM, CNA1 explained the specialty care unit housed 17 residents with a diagnosis of dementia and all cabinets and refrigerators must be kept secure and contents inaccessible for safety reasons. On 09/23/2025 at 8:20 AM, a Licensed Practical Nurse (LPN) explained all cabinets and refrigerators must remain locked and inaccessible because confused residents may ingest chemicals and food and non-food items. The LPN revealed there was one resident who was known for pulling on the cabinets, getting and ingesting sugar packets. On 09/23/2025 at 8:22 AM, CNA2 identified the resident the LPN was referring to as Resident 200 who was often seen opening and rummaging through the cabinet containing condiments and often ate the sugar packets. CNA2 confirmed there were more than 200 packets of sugar, more than 100 packets of artificial sweetener, a box of salt packets and a variety of condiments which were supposed to be inaccessible given the unit's resident population.

Based on observation, interview, and document review, the facility failed to ensure the temperature, dating, and labeling of food in residents' personal refrigerators were properly monitored for 3 of 51 sampled residents (Resident 1, 2 and 136) and one unsampled resident (Resident 125). The deficient practice had the potential to lead to foodborne illness.Findings include:1) On 09/25/2025 at 10:45 AM, a Licensed Practical Nurse (LPN), indicated Certified Nursing Assistances (CNAs) were responsible for cleaning the resident personal refrigerators weekly and on weekends. The LPN observed Resident 2's personal refrigerator and agreed the refrigerator was dirty and freezer had a buildup of ice and needed to be cleaned.The LPN explained, food brought in by family members must be stored in the refrigerator for no more than three days (72 hours). The LPN verbalized if the food remained beyond the expiration date, it was to be discarded by the CNAs. The LPN stated food must be dated either by staff or by the family. The LPN reiterated food items with manufacturer expiration dates must be discarded when expired.2) An LPN verified the temperature in R125's personal refrigerator was 50 degrees Fahrenheit. The temperature in R1's refrigerator was 42 degrees Fahrenheit.On 09/25/2025 at 11:14 AM, Certified Nursing Assistant 6 (CNA6) indicated CNAs were responsible for checking and cleaning residents' personal refrigerators if they were dirty. The CNA was unsure who was responsible for checking the refrigerator temperatures and had not checked the temperature. The CNA explained food brought in by family members must be dated and remained in the refrigerator for three days. After three days the food was discarded. The CNAs informed the resident the food had expired before the food was discarded. On 09/25/2025 at 11:19 AM, Certified Nursing Assistant 7 (CNA7) verbalized CNAs checked and cleaned residents' personal refrigerators daily. The CNA explained all food must be dated and labeled with an expiration date of 72 hours (three days). The CNA acknowledged before discarding any food the CNAs explained to the residents why the food had to be discarded. CNA7 revealed housekeeping was responsible for checking the refrigerator temperatures and logging them.On 09/25/2025 at 11:25 AM, Certified Nursing Assistant 8 (CNA8) was not aware who was responsible for checking residents' personal refrigerators. CNA8 did not know who was required to date the food when it was brought in by family members or from the outside, especially if they had not already had date, or a label. CNA8 acknowledged was food should remain in the refrigerator for three days.On 09/25/2025 at 11:30 AM, Certified Nursing Assistant 9 (CNA9) verbalized CNAs were responsible for checking residents' personal refrigerators for expired or spilled food. CNA9 explained that food would be discarded after three days. CNA9 indicated CNAs were responsible for labeling food with the date if the family or resident had not already done so. CNA9 was unsure who was responsible for checking the refrigerator temperatures.On 09/25/2025 at 11:45 AM, a housekeeper mentioned housekeeping checked residents' personal refrigerators daily and cleaned both the inside and outside each day. The housekeeper added if any food appeared to be spoiled, housekeeping would discard it with the permission from the resident. The housekeeper was not responsible for dating the resident's food.On 09/25/2025 at 11:55 AM, a Housekeeping and Laundry Manager indicated housekeeping staff checked residents' refrigerators daily for spilled food or if it was dirty and performed a full cleaning once a month due to having 24 rooms to clean. The Housekeeping and Laundry Manager explained resident personal refrigerator temperatures were checked daily but not documented in a logbook. The Housekeeping and Laundry Manager noted if a resident refused staff access to clean the refrigerator, they would not proceed.The facility had no specific policy related to residents' personal refrigerators.On 09/25/2025 at 11:00 PM, Director of Nursing (DON), indicated all the staff was responsible for cleaning residents' personal refrigerators, and was a team effort. The DON explained food brought in by families must be dated and stored for no longer than 72 hours, the same policy as the facility's main refrigerators. The DON added that the resident personal refrigerator temperatures were logged by maintenance staff and recorded in their logbook. The DON confirmed the personal refrigerator for R125, R1, R2 and R136 needed to be cleaned, food needed to be dated, and expired food should have been discarded. The DON acknowledged expired food poses a risk of causing foodborne illness.R125's personal refrigerator was found to be unsecured and unsteady on top of the resident's chest of drawers. The DON noted that if the refrigerator door was pulled forcefully, the unit could tip over, presenting a safety hazard.On 09/25/2025 at 12:00 PM, the Administrator confirmed the facility did not have a policy specific to residents' personal refrigerators. The Administrator indicated the existing policy pertained to food brought in by family members or visitors.On 09/25/2025 at 2:00 PM, the Maintenance Director indicated maintenance staff did not monitor the temperatures of residents' personal refrigerators. The Maintenance Director explained maintenance, checked the facility's refrigerators and addressed repairs as needed. Maintenance provided thermometers for use in residents' personal refrigerators.On 09/25/2025, at 3:17 PM, the Administrator, indicated family members were expected to label and date food items placed in residents' personal refrigerators, as they were the ones bringing the food for their loved ones.On 09/26/ 2025 at 8:14 AM, a Director of Dining Services indicated food stored in residents' personal refrigerators should be maintained at a temperature between 30 degrees Fahrenheit and 40 degrees Fahrenheit.The facility policy titled Foods Brought by Family/Visitors, revised October 2017, documented food brought into the facility by family/visitors that was left with the resident to consume later, would be labeled and stored appropriately and the nursing staff would discard perishable foods on or before the use by date. The facility utilized safe food handling guidelines which documented food should be kept at 40 degrees Fahrenheit or cooler.

Based on observation, interview and document review, the facility failed to ensure cabinet and refrigerator locks were in working condition in the specialty care unit. The deficient practice had the potential to pose a safety risk to residents with dementia who resided in the unit.Findings include:On 09/23/2025 at 8:10 AM, an inspection of the specialty care unit revealed two wooden cabinets and a staff refrigerator with broken locks. The Director of Maintenance turned the locks and confirmed the cabinet and refrigerator locks were broken. Certified Nursing Assistant 1 (CNA1) indicated the first cabinet contained food condiments and plastic cutlery while the second drawer contained three opened bottles of dish soap.On 09/23/2025 at 8:15 AM, CNA1 explained the specialty care unit housed 17 residents with a diagnosis of dementia and all cabinets and refrigerators must be kept secure and contents inaccessible for safety reasons.On 09/25/2025 at 8:44 AM, a revisit to the specialty care unit revealed the first cabinet was missing a drawer face and had no knob while the bottom drawer had a broken lock which made contents easily accessible by staff and residents. The locks on the second drawer and the staff refrigerator remained broken.On 09/25/2025 at 8:46 AM, CNA3 verbalized the broken cabinet, and locks had been broken for almost one month and CNA3 recalled running into one of the maintenance staff members and mentioned the issues in the unit. CNA3 acknowledged not completing a maintenance work order form for the broken equipment.On 09/25/2025 at 8:50 AM, R200 was observed approaching the first cabinet and pulled the handles but was redirected by staff before accessing the cabinet contents.On 09/25/2025 at 8:52 AM, a Licensed Practical Nurse (LPN) indicated cabinet and refrigerator locks had been broken for nearly a month. The LPN provided the Maintenance Work Request Log binder which revealed the unit did not have any outstanding request for repair. The LPN explained the cabinet and refrigerator locks were broken when the LPN returned from vacation, so the LPN assumed someone else put in a work order for repair.On 09/25/2025 at 11:20 AM, the Director of Maintenance and another maintenance staff member explained each nurses' station had a maintenance binder where nursing staff could document request for repair of equipment. The maintenance staff explained there was one method for requesting repair of equipment and this was by using the maintenance log. Verbal requests were not acceptable because it would be easy for maintenance to forget especially when the request was mentioned while the maintenance was busy with another task. The Director of Maintenance indicated most requests were repaired within 24 hours from receipt unless and confirmed there were no work requisitions received by maintenance staff regarding the broken cabinet and locks.The facility policy Homelike Environment, revised February 2021, documented residents were to be provided a safe environment.

Based on interview and record review, the facility failed to ensure the water management plan was enforced. Findings include: During a complaint investigation, it was determined the facility had not been following the facility policy titled, Legionella Water Management Program, dated [DATE]. The policy contained a checklist of items to inspect, the frequency to inspect them, and how to inspect the items. The checklist documented, Record All Actions Taken in Your Water Management Plan Binder - Section 9. On [DATE] at 10:30 AM, the Administrator and Maintenance Director explained the facility became aware of a possibility of Legionella in the building's water system when representatives from Southern Nevada Health District (SNHD) came to the facility on [DATE]. The facility was informed two prior residents had tested positive for Legionella and SNHD and a representative from Health Care Quality and Compliance (HCQC) were at the facility to consult with the facility's team to ensure safety. The Maintenance Director explained there was little documentation of testing performed between the establishment of the facility's Water Management Program, and the visit from SNHD on [DATE]. The prior residents that had subsequently tested positive for Legionella were Resident #1 and Resident #2: Resident #1: Resident #1 was admitted on [DATE], with diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease, pulmonary fibrosis, Guillain Barre syndrome, COVID, dependence on supplemental Oxygen, history of tracheostomy, and hypercapnia. On [DATE] at 5:30 PM, Resident #1's SpO2 was 85% on three Liters Per Minute (LPM) of Oxygen. A DuoNeb nebulizer treatment was administered, but was temporarily effective, and the resident's SpO2 decreased to 85%. A Combivent nebulizer was administered and was ineffective. The resident's SpO2 was 85% on 4 LPM of Oxygen. 911 was called, and the resident was transferred to the emergency department of an acute care facility. Resident #1 did not return to the Skilled Nursing Facility, and no subsequent documentation was available. Resident #2: Resident #2 was admitted on [DATE] with diagnoses that included acute and chronic respiratory failure, atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure, and chronic kidney disease. On [DATE] at 1:44 PM, the resident was transported via stretcher for persistent, productive cough post antibiotic treatment. The resident was admitted to an acute care facility. Medical records from the receiving acute care facility indicated on [DATE] at 12:30 AM, Resident #2 had a urine test, the results of which were Presumptive Legionella pneumophila, serogroup 1 Antigen POSITIVE. On [DATE] at 5:57 PM, a nasopharyngeal swab result was Legionella species by Qualitative PCR : Not Detected. Resident #2's Infectious Disease Consult, dated [DATE], indicated the resident was on 2 LPM via nasal cannula and SpO2 was 100%. The resident was on antibiotics including piperacillin-tazobactam and doxycycline. The plan was to discontinue the antibiotics and introduce Azithromycin. The Physician documented to inform the health district of the positive Legionella result. Resident #2's Discharge Summary from the acute care facility, dated [DATE], documented the resident feels much better and was being transferred to another facility. Resident #2's facesheet indicated Resident #2 was readmitted on [DATE]. The resident expired on [DATE] at 11:50 AM. On [DATE] at 9:30 AM, the Director of Nursing (DON), explained had previously been the facility's Infection Preventionist during the remediation of the water system made through SNHD and HCQC. The DON explained was aware these two residents had been transferred to other facilities and had tested positive for Legionella. The two residents had testing to determine the source of the pathogen, but testing was inconclusive and could not be determined. On [DATE], the Administrator provided a copy of the Legionella Water Management Program (LWMP), dated [DATE]. The LWMP was reviewed and found to be adequate for the type of facility and resident population. Specific issues or concerns within the plan were noted: -The plan was dated [DATE]. No evidence was provided to indicate the LWMP had been reviewed periodically. - The LWMP included a list of actions designed to mitigate the presence of legionella in the water. The facility staff were to complete and document certain activities on weekly, monthly, quarterly, semi-annual, and annual basis. Activities included but were not limited to temperature checks, flushing of pipes and fixtures, cleaning of systems such as ice machines, eye washes, and therapy pool. - Included in the LWMP was a water system flow diagram specific for this facility. The diagram was not clear in presenting the water flow within the facility. - The LWMP also had a diagram indicating the locations of where control measures should be taken periodically. - The LWMP had a list of items the facility was to check weekly, monthly, quarterly, etc. The list was not written specifically for this facility but was written for a facility in Missouri. On [DATE], the Maintenance Director (MD) was interviewed concerning the facility's LWMP. When asked for documented evidence that the LWMP had been implemented as far back as 2019, the MD explained the facility had conducted some of the activities but there was no documentation to support allegation of compliance. The MD did provide documented evidence that some of the indicated activities were being documented, but the documentation began in [DATE] when the facility was notified by the local health department, the facility may have active legionella on the property. On [DATE], the Administrator confirmed the LWMP had not been reviewed except when the facility had been notified about possible legionella concerns within the facility June of 2024. The Administrator further explained, the facility had been notified in June of 2024 concerning possible cases of legionella coming from their facility by the local health department. Water testing for legionella had been accomplished in June and July of 2024 that provided verification some samples were positive for legionella. A consultant was hired, and mitigation steps were activated starting in [DATE]. Flushing of water systems, changing of filters, cleaning of faucet equipment and hyperchlorination was accomplished. Documentation was provided indicating those activities had been accomplished. On [DATE], the Administrator provided a copy of water analysis for [DATE]. Legionella testing was conducted, and no legionella was detected. The Administrator indicated in an interview on [DATE] that the facility was in the process of developing an updated LWMP through a new vendor. No timeline was provided.

Based on interview, record review and document review, the facility failed to ensure a resident was kept safe from abuse for 1 of 5 sampled residents (Resident 4). The deficient practice had the potential for the resident to experience emotional distress and physical harm. Findings include: Resident 4 (R4) R4 was readmitted to the facility on [DATE] with diagnoses including cerebral palsy, depression, anxiety disorder, and diabetes mellitus. The resident had a brief interview for mental status (BIMS) evaluation with a score of 15, denoting the resident's cognition is intact. Resident 5 (R5) R5 was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage, chronic respiratory failure, dementia, and depression. The resident had a brief interview for mental status (BIMS) evaluation with a score of 15, denoting the resident's cognition is intact. The facility reported incident (FRI) dated 02/19/2024 documented the following: -On 02/19/2025 at approximately 1:45 PM, R4 reported to the Director of Social Services (DSS) and the Administrator that in December of 2024, R5 had touched R4's chest under the shirt. R4 stated R5 did this without permission. - R5 was interviewed and admitted to touching R4's chest one time and knew it was wrong and would never do it again. -Conclusion: The allegation of abuse by R5 against R4 was substantiated. The police department was contacted and responded to the notification of the incident. The police stated R5 had reached down R4's shirt and touched the chest. However, due to circumstances, lack of witness, and their stories not exactly lining up, no arrest would occur. Instead, a report would be filed with the District Attorney for determination if a warrant would be issued. The DSS investigative notes documented R4 had not told any staff about the situation, but did tell a relative. The relative confirmed R4 had told the relative of the situation but was not sure why the resident had not let the facility know of the allegation. Skin Assessments dated 12/03/2024, 12/06/2024, 12/13/2024, 12/24/2024, 12/27/2024, and 12/31/2024 documented R4 had head-to-toe skin checks performed to check for any skin issues. On 12/13/2024, a skin rash on the upper left chest was notated. All other dates documented clear skin. R4 had no complaints of pain or discomfort in the chest area during December 2024. A behavioral Care Plan dated 01/24/2025 documented R5 was making sexual comments toward others. Interventions included praising good behaviors, positive feedback, education on inappropriate behaviors, and to minimalize potential behaviors. A behavioral Care Plan revised on 01/24/2025, documented R4 was making false accusations and having physical altercations toward others. Interventions included anticipating resident needs, coping strategies, education on inappropriate behaviors, and to divert attention. Social Services progress notes dated 02/19/2025 documented R5 was no longer able to eat in the dining room and had to eat in the Unit one dining area, was not allowed to participate in group activities and was being put on one-to-one activities and was no longer allowed to visit unit four. Nursing progress notes dated 02/20/2025 documented R5 was placed on visual checks every 15 minutes to monitor the resident's behaviors. Social Services progress notes dated 02/20/2025 documented R5 had been moved from the 900 hall to the 500 hall to put more space between R4 and R5. On 05/22/2025 at 2:05 PM R4 stated this incident happened a while ago. R4 said does not think about the incident anymore as R5 was moved to another facility in a neighboring city. R4 stated R5 touched the resident inappropriately on the chest. R4 reported no psychosocial harm from the incident and reported was also not experiencing any emotional distress from the incident The facility policy titled Abuse, Neglect and Exploitation, Freedom From revised 09/2022, documented it is their policy to maintain a living environment where residents are free from threat or occurrence of harassment, abuse, neglect, corporal punishment involuntary seclusion and misappropriation of property. During the onsite investigation on 05/22/2025, the facility's correction of the past non-compliance related to the incident occurred as evidenced by: -Observation of resident interactions were respectful and courteous. -Interviews with residents revealed they were happy with staff and were treated in a polite manner. - CNA's and Licensed Nurses indicated the facility provided continuing education regarding Abuse and Neglect. -R5 was separated from R4 with R5 being continuously monitored. -R5 was discharged to another long-term care facility on 02/24/2024. -Review of the facility's training records corroborated the staff interviews regarding training. Facility Reported Incident #NV00073489

Based on interviews, record review, and document review, the facility failed to ensure the wrong medication was not administered to a resident for 1 of 5 sampled residents (Resident 3). The deficient practice placed the resident at risk for kidney transplant complications. Findings include: Resident 3 (R3) R3 was admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD), and kidney transplant status. A physician order dated 02/24/2022 documented to give Tacrolimus 0.5 milligram (mg), one capsule (a form of oral medication made of a gelatin or plant-based shell filled with powder, liquid, or granules) by mouth once a day for kidney transplant. (Tacrolimus- an anti-rejection medication prescribed to patients who receive organ transplant for the purpose of suppressing immune response). A medication error report dated 01/25/2025 revealed R3 was administered Cialis 5 mg tablet (a form of oral medication in solid form of compressed powder which may be coated, scored, or split) on 01/18/2025, 01/19/2025, 01/20/2025, 01/21/2025, 01/22/2025, and 01/23/2025 (six doses). According to the report, R3 was erroneously given Cialis instead of Tacrolimus due to pharmacy mislabeling a medication bubble pack. The medical record lacked documented evidence R3 was prescribed Cialis (a medication primarily used to treat erectile dysfunction and benign prostatic hyperplasia or BPH). On 05/22/2025 at 09:30 AM, a Licensed Practical Nurse (LPN1) confirmed administering Cialis to R3 on 01/19/2025, 01/20/2025, 01/21/2025, 01/22/2025, and 01/23/2025 by mistake because the medication pack was mislabeled. LPN1 verbalized medications were administered based on the five rights of medication administration including right patient, right drug, right dose, right route and right time. LPN1 explained medications were verified by looking at the label on the medication package and ensuring it was a medication ordered by physician and for the intended resident. LPN1 reviewed photo documentation of a medication bubble pack containing yellow tablets labeled as Tacrolimus 0.5 mg capsule with R3's sticker label. LPN1 acknowledged the failure to recognize the bubble pack contained medication in tablet form instead of capsule form. The LPN could not speak to why the mislabeled medication was not questioned until after the sixth dose. On 05/22/2025 at 11:30 AM, a Licensed Practical Nurse (LPN2) verbalized the medication would be verified by comparing the physician order in the electronic health record (EHR) to the label on medication card, and ensuring the medication was dispensed to the intended resident using name and photograph in the EHR. During medication pass the nurse would explain each medication to the resident. On 05/22/2025 at 12:38 PM, the Director of Nursing (DON) indicated being familiar with R3's medication error wherein the investigation revealed the pharmacy erroneously labeled a medication pack of Cialis as Tacrolimus in R3's name. The DON acknowledged LPN1 administered Cialis instead of Tacrolimus to R3 on 01/19/2025, 01/20/2025, 01/21/2025, 01/22/2025, and 01/23/2025. The DON indicated LPN3 who was assigned to R3 on 01/24/2025, noticed the Tacrolimus presented as tablet form and reported the discrepancy to management. The DON indicated the pharmacy confirmed R3's medication bubble pack was mispacked with Cialis tablet instead of Tacrolimus capsule labeled with R3's name. The DON indicated the order should have been clarified based on the label identifying medication as a capsule with a tablet being in the bubble pack. The DON verbalized nurses assigned to R3 should have identified the error before R3 received the first dose on 01/18/2025. On 05/22/2025 at 1:35 PM, the Consultant Pharmacist indicated when medications were supplied from the pharmacy, a technician or pharmacist would pack the medications and apply the label. The Pharmacist would have the ultimate responsibility to ensure the medication pack was accurate prior to sending to facility. The Consultant Pharmacist revealed the medication should be verified several times by the pharmacy and facility prior to administration. On 05/22/2025 at 2:08 PM, a Registered Nurse (RN) at R3's dialysis clinic indicated being R3's primary nurse since R3's admission on 02/07/2022. The RN explained R3 underwent a kidney transplant in 2013 until the transplanted kidney started showing signs of rejection, specifically, kidney function had significantly declined making dialysis (renal replacement therapy) necessary. The RN indicated being aware R3 was on the anti-rejection medication Tacrolimus which the nephrologist wanted the resident to continue taking because the transplanted kidney had not been removed from the resident and could initiate an immune response. The facility policy titled Administration Procedures for All Medication (revised November 2011) documented to review the five rights of medication three times prior to giving medication. Check the label against the order on the medication administration record. The facility policy titled Medication Ordering and Receiving from Pharmacy (revised November 2011) documented improperly or inaccurately labeled medications were rejected and returned to the dispensing pharmacy. Complaint NV00073304

Based on observation, interview, record review, and document review, the facility failed to ensure the residents' behavior was monitored and documented for residents receiving psychoactive medications for 6 of 25 sampled residents (Residents 44, 102, 5, 161, 4, and 99). This deficient practice could have increased the risk of adverse side effects, ineffective medication management, missed signs of worsening conditions, and compromised resident safety. Findings include: A facility policy titled Medication Monitoring and Management revised in November 2014, indicated the resident's medication regimen required monitoring for significant negative changes from baseline. Medications were to be ruled out as the cause of these changes, following the policy on detecting and preventing adverse consequences. Resident 44 (R44) R44 was admitted on [DATE], with diagnoses including depression, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Physician Order dated 09/01/2024, documented Donepezil Hydrochloride (HCL) oral tablet milligrams (mg) to give 1 tablet by mouth at bedtime related to dementia. A Physician Order dated 09/01/2024, documented Sertraline HCL tablet 25 mg to give 1 tablet by mouth daily for depression due to verbalization of sadness over health condition. A Physician Order dated 09/01/2024, documented Risperidone tab 0.5 mg to give one tablet by mouth two times daily for psychosis manifested by (MB) yelling and swinging at staff and others. R44's medical record lacked documented evidence there were orders to monitor target behaviors and side effects for the use of psychoactive medications. On 09/26/2024 at 12:00 PM, the Clinical Care Coordinator (CCC) explained the facility had transitioned from one electronic health record (EHR) system to another. The new EHR system was fully implemented, and a third party was hired to ensure everything transferred successfully. The CCC took responsibility for auditing and ensuring the necessary orders were in place, as direct care staff no longer had access to the previous system. The CCC confirmed Licensed Nurses were expected to monitor residents' behavior and adverse effects of psychoactive medications, documenting either in the progress notes or on the printed medication administration record. The CCC acknowledged inconsistent monitoring of residents' behaviors and side effects related to psychoactive medications. 37718 Resident 102 (R102) R102 was admitted on [DATE] with diagnoses including Wernicke's Encephalopathy (a type of dementia). A physician order dated 08/31/2024, documented Xanax (a sedative) 0.5 mg give 1 tablet by mouth three times a day for anxiety. A physician order dated 08/27/2024, documented Lamictal (an anticonvulsant) 25 mg to give 1 tablet by mouth daily for depression. A physician order dated 08/27/2024, documented Risperidone tab 2 mg one tablet by mouth at bedtime for psychosis. A physician order dated 08/27/2024, documented Zoloft tablets, 25 mg, give three tablets by mouth at bedtime for depression. The September 2024 Medication Administration Record indicated all medications were given as ordered. R102's medical record included nurse progress notes documenting R102's exit-seeking behavior and verbalizing of delusional statements. These notes were documented at irregular intervals. R102's medical record lacked physician orders for the monitoring of behaviors and for side effects of the psychoactive medications. On 09/27/24 at 10:16 AM, the Licensed Practical Nurse (LPN) verbalized caring for R102 today and on a regular basis. The LPN reported R102's behavior and medication side-effects were assessed and then documented in the progress note section of the electronic health record (EHR). The LPN verbalized the facility had recently changed to a different EHR system. Under the former EHR system, monitoring of medication side effects and of behaviors was ordered by the physician and the licensed nurse documented monitoring was carried out on the MAR. The LPN revealed the new EHR system was in transition, and documenting on the MAR was not available in the new system. The LPN revealed they had been instructed to document side effect and behavior observations in the progress note section of the new EHR. 40142 Resident 5 (R5) R5 was admitted on [DATE], with diagnoses including unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A physician's order dated 08/29/2024, documented to give Seroquel Oral Tablet 25 mg, one tablet by mouth at bedtime for psychosis. The medical record lacked documented evidence there were orders to monitor target behaviors and side effects for R5 's Seroquel use. A physician's order dated 08/29/2024, documented to give Prozac 10 mg (anti-depressant), three capsules by mouth one time a day for depression. The medical record lacked documented evidence there were orders to monitor target behaviors and side effects for R5 's Prozac use. 50289 Resident 161 (R161) R161 was readmitted on [DATE], with diagnoses including generalized anxiety disorder and dementia. R161 physician's orders listed the following psychotropic medications: 1) SEROquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth at bedtime for psychotic disturbance, order date: 08/24/2024. R161's ordered psychotropic medications were marked by the EHR system with a black box warning (serious adverse reactions or special problems occur, particularly those which may lead to death or serious injury). R161's September medication administration record (MAR) lacked documented evidence psychotropic medication adverse reaction monitoring was completed. R161's nurses progress notes revealed no entries for the monitoring of psychotropic medication side effects. 39418 Resident 4 (R4) R4 was admitted on [DATE], with diagnoses including delusional disorder and psychosis. R4 physician's orders listed the following psychotropic medications: 1) FLUoxetine Hydrochloride Oral Capsule 20 milligrams (MG) (Fluoxetine HCl), Give 1 capsule orally one time a day for major depression, as evidenced by (AEB) self-isolation, order date: 8/24/2024. 2) ZyPREXA Oral Tablet 5 MG (Olanzapine), Give 1 tablet by mouth one time a day for schizophrenia, order date: 08/24/2024. R4's comprehensive care plan for Problem documented: Risk for adverse consequence related to receiving psychotropic medications Zyprexa for schizophrenia and Prozac for depression. Category: psychotropic Drug Use dated 07/07/2024, documented a listed intervention of monitor and report signs of sedation, anticholinergic and /or extrapyramidal symptoms (group of side effects that can occur as a result of taking certain medications, especially antipsychotics. Resident 99 R99 was admitted on [DATE], with diagnoses including psychosis and bipolar. R99 physician's orders listed the following psychotropic medications: 1) busPIRone HCl Oral Tablet 7.5 MG (Buspirone HCl), Give 1 tablet by mouth three times a day for anxiety, order date: 8/28/2024. 2) Escitalopram Oxalate Oral Tablet 5 MG (Escitalopram Oxalate), Give 1 tablet by mouth one time a day for Depression, order date: 8/28/2024 3) Depakote extended release (ER) Oral Tablet Extended Release 24 Hour 250 MG (Divalproex Sodium), Give 1 tablet by mouth two times a day for Bipolar, order date: 8/28/2024. 4) SEROquel Oral Tablet 50 MG (Quetiapine Fumarate), Give 1 tablet by mouth at bedtime for psychosis, order date: 8/28/2024. R99's comprehensive care plan for Care Plan documented: Problem: Resident is at risk for adverse consequence related to receiving psychotropic medication buspirone and escitalopram. diagnosis: anxiety and depression. Depakote diagnosis: Bipolar. quetiapine diagnosis: psychosis. R4 and R99's ordered psychotropic medications were marked by the EHR system with a black box warning (serious adverse reactions or special problems occur, particularly those that may lead to death or serious injury). R4 and R99's, September medication administration record (MAR) lacked documented evidence psychotropic medication adverse reaction monitoring was completed. R4 and R99's, nurses progress notes revealed no entries for the monitoring of psychotropic medication side effects. On 09/26/2024 at 2:06 PM, the 300 Hall nurse indicated documentation of the side effect of any psychotropic medication would be placed on the MAR. On 09/26/2024 at 2:15 PM, the Unit 4 nurse indicated the new electronic healthcare record (EHR) does not have the side effects monitoring and for now documentation of monitoring would be on the progress notes. On 09/27/2024 at 9:59 AM, the 300 Hall nurse indicated with the previous EHR, side effect monitoring was completed on the MAR on a shift-to-shift basis. With the new EHR switch over, migration of the orders for side effect monitoring did not occur. The nurse indicated directives where side effects monitoring should be documented on the progress notes. On 09/27/24 at 10:26 AM, the Clinical Care Coordinator (CCC) indicated facility was aware of some of the order sets did not migrate over to the new EHR. The CCC indicated the regional nurse prior to the implementation of the new EHR, had printed the MAR and the nurses were expected to chart on it or enter side effect monitoring onto the progress notes. The CCC acknowledged nurses were not too keen into charting into paper MAR and the progress notes. The CCC indicated nursing staff is still pending for training into entering the orders sets into the HER, preventing an updated side effect monitoring for the side effects. The CCC acknowledged without the consistent side effect monitoring charted into the MAR, there was lack of monitoring documentation for the side effects of psychotropic medication and the side effects monitoring was essential for the physician and pharmacist for the resident drug review. The facility policy titled Medical Regimen Review Policy (undated), documented Medication Review: will be conducted monthly. The medical regimen review should consider the potential drug interactions, side effects, and any adverse reactions. The facility policy titled Medication Monitoring and Management revised 11/2014, documented to optimize the therapeutic benefit of medication therapy and minimize or prevent adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective and safe medication use.

Based on interview, record review and policy review, the facility failed to assess and implement interventions to prevent weight loss for 5 of 29 sampled residents (Residents #4, #7, #16, #17, and #26). Findings include: The facility's policy titled Weight Assessment and Intervention, dated 2014, the multidisciplinary team will prevent, monitor, and intervene for the undesirable weight loss of residents and the weights will be documented in the individual resident's health record. Any weight change of 5% or more since the previous weight assessment taken again the next day to confirm. If the weight is verified, nursing will notify the Dining Services Manager in writing immediately. The Registered Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends. Negative trends will be evaluated by the treatment team to determine whether or not significant weight change has occurred. The threshold for significant unplanned and undesired weight loss shall be based on the following criteria (where percentage of body weight loss = (usual weight - actual weight)/ (usual weight ) X 100). The policy indicated a loss of 5% in a month, 7.5% in three months and 10% in six months were a significant weight loss. The policy indicated greater than 5% in a month, greater than 7.5% in three months, and greater than 10% in six months were a severe loss. The policy further indicated if the weight change is desirable, it will be documented and no change in the care plan will be necessary. According to the document, the multidisciplinary team were to analyze the weight loss of a resident and develop an individualized care plan and interventions to address the loss. The facility's policy titled Resident Weight Monitoring, dated 2014, indicated residents capable of standing will be weighed on a standing scale. Residents incapable of standing will be weighed on a wheelchair or bed scale. Residents with significant weight changes or questionable weights will be reweighed for verification .Weight gain or loss of 5% in one month should be reported to the physician. Resident #7 Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/19/16, the Registered Dietitian documented the resident's usual weight was 100-105 pounds. Resident #7's monthly and weekly tracking sheets indicated on 1/5/16, the resident weighed 122.6 pounds. The resident was reweighed on that day and weighed 116 pounds. On 1/12/16 the resident weighed 112.6 pounds. On 1/19/16 the resident weighed 107 pounds. On 1/26/16 the resident weighed 105 pounds. On 2/9/16 the resident weighed 108.4 pounds. On 3/1/16 the resident weighed 83.8 pounds; a 22.69% reduction in weight. On 4/1/16 the Registered Dietitian (RD) was interviewed in the presence of the Director of Nursing and the Regional Nursing Supervisor. The RD was shown Resident #7's weights from the tracking sheets. The RD stated I don't know how I missed that. The RD stated the process was to reweigh a resident with more than a 5% reduction in weight and make a recommendation and a note in the progress note. The RD acknowledged the recommendation, note and reweigh were not done. On 3/31/16, the Director of Nursing stated Resident #7 had been reweighed and weighed 105 pounds. The DON stated the recorded weight discrepancy should have been followed up to address what was likely a subtraction error in the residen'ts weight. Resident #26 Resident # 26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The recapitulation orders for March 2016 documented the resident was on a regular, no added salt (NAS) diet The Monthly Weight Tracking Sheet documented the resident weights as follows: December 1, 2015 - 113.8 pounds January 1, 2016 - 113.12 pounds February ,1 2016 -113.0 pounds March 1, 2016 - 101.8 pounds (a decrease of 11.2 pounds). April 1, 2016 - 100.12 pounds ( a decrease of 1.68 pounds) Documentation entitled Nutrition Assessment documented the resident's height was 60 inches. The documentation indicated a quarterly review had been completed on 3/15/16. The resident's weight was documented at 101.8 pounds, a quarterly weight change of 12.72 (12%). The assessment revealed the resident was able to feed herself and her meal intake percentages were 50% to 80%. The resident accepted snacks at H.S. (hour of sleep). The area on Nutrition Assessment form to document goals and interventions indicated the resident was down 11 pounds in 30 days and down 11 pounds in 6 months. The documentation indicated the resident was cutting back on meals wanted to lose weight, [MEDICAL CONDITION] getting worse. The Nutritional Assessment form was signed by the Assistant Dietary Manager on 3/15/16 and signed by the Registered Dietician (RD) on 3/19/16. The Minimum Data Set ((MDS) dated [DATE] documented the resident's height as 60 inches and her weight as 102 pounds. The MDS documentation indicated there was a weight loss and the resident was not on a physician prescribed weight loss regimen. The clinical record contained a Dietary Assessment note with the last dated entry of 1/6/16. The dietary assessment notes lacked documentation the Registered Dietician (RD) had spoken to the resident about a weight reduction program or documentation which indicated the resident wanted to lose weight. The clinical record lacked documentation the resident's likes and dislikes had been updated since 12/13/14. The clinical record contained a care plan with the category: Nutritional Status: potential for weight loss related to [DIAGNOSES REDACTED]. The therapeutic diet was documented as NAS diet. The documented approaches on the care plan included: assist with meals, laboratory as ordered, monitor weight trends, monitor daily intake and record and serve NAS diet as ordered. The care plan contained documentation with the date 3/15/16 down 11 pounds in 30 days and down 11 pounds in 6 months. The care plan lacked documented evidence of interventions after the 11 pound weight loss. The care plan lacked documented evidence the resident was on a weight loss regimen/program. The clinical record lacked documented evidence of the following: The resident's physician had been notified of the 11.2 pound weight loss in 30 days. The resident's likes and dislikes were evaluated after the weight loss on 3/1/16. The resident had been assessed after the 11.2 pound weight loss Interventions were put into place after the weight loss on 3/1/16. The Registered Dietician had evaluated the resident for a planned weight loss program. The Registered Dietician discussed a planned weight loss program with the resident and if the resident was in agreement with the plan. A care plan had been developed for a weight reduction program with parameters for safe weight loss. On 3/30/16 at 1:00 PM, a LN verbalized when a resident had a weight decrease from the previous months weight up or down more than #5 pounds the family and physician were called. The physician would be asked what supplement or medication were to be given to increase the appetite. The resident would be re-weighed prior to the physician being contacted. The Director of Nursing (DON) monitored the weights and would tell staff who to re-weigh and for what residents to call the physician. The LN revealed the CNA assigned to resident completed the weight and if there was a large gap in the weight the LN was to check the weight. The LN revealed she was not sure if the Registered Dietician evaluated the residents monthly or quarterly. On 3/30/16 at 1:50 PM a CNA verbalized if a resident had a weight decrease she would take the resident off the scale and get the nurse. The resident would be put back on the scale and the nurse would be shown the weight. The weights were given to the nurse. If a re-weigh was requested a list was put out at the nurses station of those residents who needed to be re-weighed. The re-weigh was usually done within 24 hours. The CNA revealed the re-weigh was done if a resident's weight was down 2-3 pounds or if the nurses told the staff to re-weigh the resident. On 3/31/16 at 3:00 PM, Resident #26 stated she was not eating enough at meals and did not like the food. The resident revealed she had lost 11 pounds. The resident verbalized she did not want to loose weight and was trying to gain weight. The resident verbalized no one from the facility had spoken with her to see if she had wanted different food. The resident revealed she liked Thai food and wanted rice with her meals. The resident indicated the residents at her table did not speak or talk during meal times. On 4/1/16 at 8:00 AM, a LN stated Resident #26's was oriented to person, time and sometimes the resident was confused. The LN stated most of the time the resident was alert and knew her needs. The LN verbalized she would find the resident credible depending upon the situation. The LN verbalized if a resident wanted to loose weight they would contact the physician and tell Dietary. The LN verbalized there were no planned weight reduction diets in house. On 4/1/16 at 8:20 AM, the Dietary Manager verbalized food preferences were done quarterly. The Dietary Manager was advised there was no documentation in the clinical record since admission Resident #26's food preferences had been updated/reviewed. The Dietary Manager revealed there was no special form and it would be documented on the RD quarterly note. On 4/1/16 at 9:00 AM, the Assistant Director of Dining Services verbalized he had spoken with the resident on 3/15/16 about her food preferences and he was aware there was no documentation in the clinical record this had been completed. The Assistant Director of Dining Services revealed there was no area on the quarterly evaluation to document this was completed. The Assistant Director of Dining Services indicated he checked meal percentages and spoke with the resident. The Assistant Director of Dining Services revealed he was not sure what the resident's cognitive status was and was told by staff the resident had cut her pants and thought she was gaining weight. The Assistant Director of Dining Services explained he was not sure if this was verbalized by the resident or not. On 4/1/16 at 9:10 AM, a CNA verbalized the resident had mentioned one day she was gaining weight, but the resident was not always dependable with what she said. The resident went to the kitchen for snacks and family and friends brought in food. On 4/1/16 at 11:45 AM, a LN was not able to locate documentation in the clinical record to show the physician and family were advised of the resident's 11 pound weight loss. The LN verbalized it was the nurse's responsibility to call the physician. The LN verbalized more than a 5 pound weight decrease was a significant weight loss. The LN verbalized the care plans were completed by the Minimum Data Set (MDS) Nurses, the Director of Nursing (DON) and the Registered Dietician. On 4/1/16 at 12:35 PM, Resident #26 consumed 65% of her noon meal per the CNA. The resident consumed half of the fish, cheesy pea salad, all of the carrots, a quarter of the noodles, 3/4 of the lemon meringue pie, 300 cubic centimeters of water and 50% of her coffee. The resident did not consume the slice of bread provided with her meal. During the noon meal observation the resident at the table with Resident #26 did not speak during the meal. On 4/1/16 at 12:50 PM, the DON verbalized she was aware of the residents 11 pounds weight loss and questioned the staff about the weight. The DON provided documentation to show the resident had been re-weighed and the weight was 101.8 pounds. On 4/1/16 at 12:53 PM, the MDS Nurse verbalized the RD did not complete the care plan. If there was a planned weight decrease or reduction the RD would make a plan, speak with the resident because the resident needed to be in agreement with the plan, set the parameters for the weight loss and document in her notes. On 4/1/16 at 2:00 PM, the RD revealed she checked in with the Dietary Manager who would have the weekly weights, wound sheets, and weight changes. Monthly weights were reviewed on the RD' s second visit of the month. If a resident had a 5 pound weight change in a month the resident would be re-weighed the same day or the next day. Once the weight was confirmed the facility would determine if the weight loss was 5%, 7.5% or 10%. The completed Dieticians Report with recommendations went to the DON and Assistant Dietary Manager. The DON provided the information to the floor/unit. Weights were reviewed at the monthly weight meetings which the facility has twice a month. The RD would be notified of weight changes by the weekly weights which the Assistant Dietary Manager generated or the weight variance reports received monthly. On 4/1/16, the RD indicated she co-signed the Assistant Director of Dining Services notes. The RD verbalized she was not able to state why the weight loss was concluded as voluntary. If a resident was on a voluntary weight loss program it should be care planned with appropriate parameters for the weight loss, and there should be documentation the resident had agreed and a plan would be in place. The RD confirmed the resident had a 11.2 pound weight loss in one month. The RD revealed she had co-signed the note without reading the documentation. The RD verbalized she missed the resident's weight loss and the resident should have been re-assessed and a monthly note completed. Resident #17 Resident # 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Monthly Weight Tracking Sheet documented the resident weights as follows: May 1, 2015 -128 pounds June 2015 - 121.12 pounds (a decrease of 6.88 pounds or 5.3% in 30 days) July 2, 2015- 121 pounds August 2, 2015 - 113.5 pounds (a decrease of 7.5 pounds or 6.2% in 30 days) September 1, 2015- 111.8 pounds (a decrease of 1.7 pounds) October 1, 2015 - 107.0 pounds (a decrease of 4.8 pounds) The clinical record lacked documented evidence of the following: The resident had been re-weighed after the 6.88 pounds weight loss in June 2015 or after the 7.5 pound weight loss in August 2015. The resident had been assessed/re-assessed by the RD after the 6.88 pounds weight loss in June 2015 or after the 7.5 pound weight loss in August 2015. Interventions had been put into place to slow or stop the weight loss of 6.88 pounds in June 2015 or after the 7.5 pound weight loss in August 2015. Interventions were initiated until 9/16/15 when a physician's orders [REDACTED]. The RD documented a progress note between 3/26/15 and 9/15/15 to address the May, June, July and August 2015 weight loss. The clinical record lacked documented evidence the resident was on a physician prescribed weight loss regimen. The Quarterly Minimum Data Set ((MDS) dated [DATE], documented the resident's height was 66 inches and her weight was 121 pounds. The MDS documented there was a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS documented yes, not on physician-prescribed weight loss regimen. The resident was on a mechanically altered therapeutic diet. Documentation entitled, Nutrition assessment dated [DATE] indicated: Diet order NCS, NAS, mechanical diet. Snacks supplements:Med pass 4 ounces and HS snack (hour of sleep). Weight 121 pounds Quarterly weight change down 5 pounds Meal intake: 60-100% Goals/Interventions: no goal or interventions documented. Nurse's Notes dated 8/2/15 lacked documented evidence the resident's physician or family had been notified of the weight loss of 113.5 pounds (a decrease of 7.5 pounds or 6.2% in 30 days) on 8/2/15. The Nurse's Notes contained only one entry documented for August 2015 which was dated 8/26/15. The 8/26/15 entry did not address the resident's weight loss on 8/2/15. Nurse's Notes dated 9/11/15 documented resident had a significant weight loss. On 9/11/15 a telephone order was received for dietary referral due to weight loss. On 9/16/15 a telephone order was received for Magic cup with lunch and dinner (per Registered Dietician (RD) recommendation). The Quarterly Minimum Data Set ((MDS) dated [DATE], documented the resident's height was 66 inches and weight was 112 pounds. The MDS documented there was a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS documented yes, on physician-prescribed weight loss regimen. The resident was on a mechanically altered therapeutic diet. Documentation entitled, Nutrition assessment dated [DATE] indicated: Diet order NCS, NAS, mechanical diet. Snacks supplements:Med pass 4 ounces Weight 111.8 pounds Quarterly weight change down 9.3 pounds Meal intake: 70- 90 % Goals/Interventions: staff assist with meals, down 14 pounds in 6 months. Magic cup twice a day now. See RD note. The Dietary Progress note dated 10/20/15 documented RD review: down weight, current body weight 107 pounds. Down 4 pounds /4.3% times 30 days, down 14 pounds/11.6% times 90 days and down 18 pounds/14.4% times 180 days. On 12/27/15 a physician's telephone order was received to clarify the residents diet as mechanical soft diet, NAS (no added salt) NCS (no concentrated sweets). On 1/13/16 a physician's telephone order was received for Magic cup at lunch and dinner. (per RD recommendation). Documentation on the telephone order indicated duplicate order. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no documentation on the back of the MAR indicated [REDACTED]. Documentation thinned from the clinical record on 3/26/16 per the MDS Nurse contained a care plan for Nutritional Status. Altered Nutritional Status related to [DIAGNOSES REDACTED]. The care plan contained documentation of a date in July 2015 (unreadable) which documented the following: down 6.9 - 5% - 30 days down 13.9 - 11% - 6 months. The care plans documented goal was: will be adequately nourished as evidenced by stable weight with no further significant weight changes. The approaches documented on the care plan included: Magic cup as ordered, serve NCS, NAS mechanical soft diet, offer snack at HS (hours of sleep) if resident desired. On 3-31-16 a noon meal observation was completed. The resident was assisted with her noon meal by a CNA. The residents tray card/meal ticket documented Magic cup with lunch and dinner. The resident's meal tray contained a vegetable, pepper steak, mashed potatoes with gravy, bread, water, lemonade and angel food cake. During the meal observation the resident was not provided the Magic cup. The CNA verbalized the resident had consumed 25 -35% of her noon meal. The CNA verbalized the Magic cup was not provided with the meal tray, it was extra food and was provided when the residents were given ice cream. On 3-31-16 at 1:20 PM, the Dietary Manager verbalized a Magic cup came frozen, but was the consistency of pudding a room temperature. The Magic cup required a physician's orders [REDACTED]. The information was then entered it into the computer data bank and the change would show up on the meal ticket/tray card. The Dietary Manager located the containers of Magic cup in the unit kitchen in the refrigerator/freezer. On 4/1/16 at 2:00 PM, the RD confirmed the following: 1. The weight loss from May 2015 to June 2015 was a 6.88 pound weight loss or 5.3 % weight loss in 30 days. The RD confirmed there was no documentation in the clinical record Resident #17 had been re-weighed, re-assessed, or interventions were put in place. The RD verbalized the resident should have been re-weighed, re-assessed and interventions put in place. 2. The weight loss from July 2015 to August 2015, was a 7.5 pound weight loss or 6.2% in 30 days. The RD confirmed there was no documentation in the clinical record the resident had been re-weighed, re-assessed, or interventions were put in place. The RD verbalized the resident should have been re-weighed, re-assessed and interventions put in place. During the interview on 4/1/16, the RD verbalized when she assessed a resident she would look at the physician's orders [REDACTED]. The RD revealed the Assistant Dietary Manager collected the data for the quarterly reviews and the RD signed them off. The RD verbalized there was no place to document the residents likes and dislikes were reviewed. The RD confirmed the updated care plan dated 3/30/16 did not contain documentation for the Magic cup with lunch and dinner. The RD confirmed the care plan should contain the supplement Magic cup. The RD verbalized she had missed both the 6.88 pound and 7.5 pound weight losses. The facility's policy entitled, Weight Monitoring dated revised 3/2013, documented Weights would be documented on the Resident Weight tracking Form. The Assistant Director of Nursing or Charge Nurse for each hall would refer to the previous months weight. If there was a five pound loss or gain this would trigger the resident to be re-weighed. The re-weigh would be obtained the following day. The Charge Nurse would complete the Weight Change Follow Up form for each resident with a significant weight loss or gain. The physician would be notified and any orders would be noted and documented in the nurse's notes. The completed Weight Change Follow Up form would be filed in the Dietary section of the chart. Weight reports would be monitored by the Charge Nurse, Dietary Service Manager, Registered Dietician, Assistant Director of Nursing/ Director of Nursing. The Weight Management Committee would meet monthly to discuss residents with weight fluctuations. A significant weight loss was defined as a resident with weight loss of 5% or more in the last 30 days, 7.5% or more in the last 3 months or 10% in the last 6 months. Documentation from the facility's Family Dining Services Policy& Procedure Manual, 2014 edition, for Unintentional Weight Loss indicated when evaluating weight it was important to take into consideration current medical conditions which included: chewing and swallowing abnormalities, functional ability and medications. Suggested parameters for evaluating unplanned or undesired weight loss were: One month 5% was a significant weight loss, greater than 5% was a severe loss. Three months 7.5% was a significant weight loss, greater than 7.5% was a severe loss. Six months 10% was a significant weight loss, greater than 10% was a severe loss. Residents identified with unintentional weight loss were referred to the interdisciplinary team and physician for follow up. Family member or the Durable Power of Attorney for Health Care were notified. The Dining Service Manager visits the resident with unintentional weight loss and initiates new, agreed upon nutritional interventions, if applicable, documents any changes to the plan of care and refers the resident to the Registered Dietician for reassessment. Documentation from the facility's Family Dining Services Policy& Procedure Manual revealed unintentional weight loss can have serious implications for older adults. Studies indicate unintentional weight loss can lead to malnutrition, poor wound healing, risk of pressure ulcers, decline in function and inability to fight infection. Unintentional weight loss can be rapid or sometimes slow and insidious. It was important systems were in place to detect, assess and develop an individualized plan of care for persons with unintentional weight loss. Resident #4 Resident #4 was originally admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 6/22/15, the Monthly Weight Tracking Sheet documented the resident's weight was 213.8 pounds. The sheet revealed on 6/29/15, the weight was 209 pounds with a variance of 4.8 pounds from the previous weight. There was no evidence the resident was re-weighed the day after due to the variance. On 7/14/15, the Monthly Weight Tracking Sheet indicated the weight was 207.6 Lb. On 8/1/15, the sheet documented the resident's weight was 192.8 pounds with a variance 8.8 pounds. There was no evidence the resident was re-weighed the day after due to the variance. There was no evidence a nurse reviewed the weight. On 9/1/15, the Monthly Weight Tracking Sheet indicated the weight was 188.4 pounds. On 10/1/15, the sheet documented the resident's weight was 170.04 pounds with a variance 18.36 pounds. There was no evidence the resident was re-weighed the day after due to the variance. There was no evidence a nurse reviewed the weight. On 11/1/15, the Monthly Weight Tracking Sheet documented the weight was 174.2 lb. On 12/1/15, the sheet documented the resident's weight was 165.6 pounds with a variance 8.6 pounds. There was no evidence the resident was re-weighed the day after due to the variance. There was no evidence a nurse reviewed the weight. On 4/1/16 at 2:00 PM, the Registered Dietitian (RD) explained if a resident had a five pound weight change in a month, the resident would be re-weighed the same day or the next day. The facility's policy titled Weight Monitoring dated revised March, 2013, documented weights would be documented on the resident weight tracking form. The Assistant Director of Nursing or Charge Nurse for each hall would refer to the previous month's weight. If there was a five pound loss or gain this would trigger the resident to be re-weighed. The re-weigh would be obtained the following day. Resident #16 Resident #16 was originally admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #16's clinical record revealed the Admission Resident assessment dated [DATE], did not document the weight. The monthly weight tracking sheet did not document the resident's weight. On 4/1/16 at 2:00 PM, the RD explained the Nurses obtained residents' weight on admission, every week for the first four weeks of hospitalization , then monthly. The RD acknowledged the resident's clinical record lacked documented evidence the weight was obtained as described above. The facility's policy titled Weight Monitoring dated revised March, 2013, read: Resident are weighed upon admission and on a weekly basis for the first four weeks to establish a baseline weight. All residents are then weighed monthly on designated day.

Based on observation, interview, record review, and policy review the facility failed to ensure a resident was transferred safely using a lift device for 1 of 30 residents (Resident #10), failed to implement an intervention based on the causal factor for 1 of 30 residents (Resident #10) and failed to ensure fall precautions were implemented after a fall for 1 of 30 residents (Resident #4). Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 1/27/14 at 9:55 AM, Resident #10 had been assisted by one certified nursing assistant into the Serita Lift (sit to stand) to be transferred from bed to wheelchair. After Resident #10 was prepared and assisted into the lift, Resident #10 slid to the floor and sustained a humeral neck fracture (upper arm region). The self report received by the Division of Public and Behavioral Health on 1/29/14 at 4:11 PM, documented the certified nursing assistant(#1) prepared to have another certified nursing assistant (#2) enter the room to help with the transfer. Certified nursing assistant #1 prepared Resident #10 without assistance from another co-worker. Certified nursing assistant #1 positioned Resident #10 on the side of the bed in the upright position. Certified nursing assistant #1 applied the sling and the belt. While the resident was in the belt and the sling, Resident #10 started to slide down and caught his left arm on the sling. The certified nursing assistant assisted Resident #10 to the floor. Staff were called for assistance which included a licensed practical nurse to "assess". The report indicated Resident #10 had a complaint of pain to the left shoulder, physician notified, X-ray ordered, and results were humeral neck fracture without displacement. The physician was notified of the results and Resident #10 was transferred to the emergency room for evaluation and treatment. Section 10 of the self report titled Conclusion dated 1/29/14, documented Resident #10 slid off the bed and weighed 263 pounds. The report indicated this was due to muscle weakness Resident #10 may need to be evaluated for a different mode of transport (Hoyer lift). The Minimum Data Set ((MDS) dated [DATE] annual assessment, documented Section G functional status sub- section B. transfers indicated total dependence with full staff performance every time. The support section was coded 3 which indicated two person physical assist. The CAA (care area assessment) section 5. Activities of Daily Living (ADL)/Rehabilitation potential documented in part Resident #10 "... needs assist 2 with Hoyer lift for transfers..." The MDS dated [DATE], quarterly assessment, documented Section G functional status sub-section B transfers total dependence indicated full staff performance every time. The support section was coded 3 which indicated two persons physical assist. The Transfer and Lift policy (butterfly) dated 10/10/11, indicated in part "....To provide communication to staff about resident transfer abilities and to assure we take all precautions necessary to maintain the safety of our residents...an aqua butterfly indicates a mechanical full body lift is required.....a pink butterfly indicates a sit to stand lift is required." The residents transfer ability will be indicated on the standard admission order sheet.....Transaction analysis reports of resident's transfer ability be run weekly and placed at each nurses station...." On 6/18/14 at 10:00 am a licensed nurse indicated a butterfly would be placed over the resident's bed to indicate if the resident used a lift or how the resident transferred. The licensed nurse indicated there would be an order for [REDACTED]. The licensed nurse indicated for any type of lift there should be two staff at all times during the transfer process. This would include application of the sling and belt for a sit to stand lift. The licensed nurse verbalized if a resident had [DIAGNOSES REDACTED] due to a stroke it would not be appropriate to use the sit to stand (Serita lift). On 6/18/14 at 10:15 AM, there was not a butterfly above Resident #10's bed or in the room. There was not a butterfly in the room or over the bed for the remainder of the survey. On 6/18/14 at 10:30, a certified nurse aide indicated during shift report resident transfers were discussed. This included if a resident used a lift the team would find out during shift report. The certified nurse aide revealed if a resident used a lift there should be two staff members to assist from preparation to completion of the transfer. The certified nurse aide verbalized staff should never prepare or transfer a resident alone when the lift was used. On 6/18/14 at 11:00 AM, Resident #10 indicated when the lift was used it caused anxiety for Resident #10. Resident #10 verbalized this was because of the fall from the sit to stand (Serita lift) and due to the fall from the Hoyer lift on the same occasion when the staff assisted him up from the floor. Resident #10 indicated while in the Hoyer lift the lift tipped over and staff was able to grab the lift and assist Resident #10 to the bed. Resident #10 verbalized this also hurt his arm. On 6/18/14 at 4:00 PM, the certified nurse aide who transferred Resident #10 verified transfer preparation was performed alone. The certified nurse aide indicated transfer should have been completed with two staff members. The certified nurse aide verbalized Resident #10 used the sit to stand lift (serita lift) for quite some time and the information was shared with staff during shift change report. On 6/18/14 in the afternoon, two nurse aides transferred a different resident (Resident #18) and used the sit to stand (Serita Lift). Resident #18 wore big puffy bunny boots. The two certified nurse aides transferred the Resident #18 with the boots on. The certified nurse aides indicated the boots had to be on at all times. The nurse aides confirmed the bottom of the boots had no grip material and could be slippery. On 6/19/14 at 4:00 PM, an observation of a different resident (Resident #18) was made for transfer from wheel chair to bed. Two certified nursing assistants were present during the entire time. The two certified nursing assistants used the sit to stand lift and agreed there was not a butterfly code in the room anywhere. The certified nursing assistants verbalized information was received during shift report on transfers. The certified nursing assistants were not aware of the butterfly lift policy. Resident #18 had a bandage on her foot and no other footwear during the transfer. The nursing assistants confirmed Resident #18 should have worn a shoe or non-slid socks during the transfer. There was not a butterfly above the bed or in the room for Resident #18 during the week of the survey. The instructions on the Serita (sit to stand) lift page 12 titled Transferring indicated in part:"....(name of the company) recommends two (2) assistants be used for all lifting preparation, transferring from and transferring to procedures....." The memo that was attached to the Serita (sit to stand) lift documented things to remember regading lifts. The last bullet documented lifts require two persons. Resident #10 care plan for ADL/functional rehabilitation dated 10/29/13, indicated total dependence with an assist of 2 persons using the Hoyer lift for transfers. On 6/19/14 at 7:40 AM, the licensed practical nurse (LPN) verbalized on 1/27/14 Resident #10 was found on the floor upon entering the room. LPN verbalized Resident #10 was not in pain and seemed "okay". The LPN indicated instructions were given to assist Resident #10 back to bed using the Hoyer lift. The LPN acknowledged a Registered Nurse did not assess Resident #10 prior to moving the resident. The LPN revealed once Resident #10 was in the Hoyer lift it did tip forward with Resident #10 in it but the staff members were able to control the balance and move Resident #10 back to bed. The LPN verbalized a Registered Nurse should have been called to assess Resident #10. The LPN confirmed he/she was the only one that completed the assessment because there was not a complaint of pain. The nurse's notes documented Ibuprofen 800 milligrams was given on 1/27/14 at 10:30 AM as Resident #10 reported pain. On 6/19/14, in the afternoon the Director of Nursing verbalized a lack of awareness regarding the Hoyer lift tipping and Resident #10 expressed fear during transfers. On 6/20/14 at 1:00 PM, the Staff Development Coordinator (SDC) revealed training was conducted on the use of the Hoyer lift on 4/9/14. The SDC acknowledged training on the Serita lift had not been conducted over the past year. On 6/20/14 at 1:30 PM, the Nursing Home Administrator (NHA) indicated a Registered Nurse should perform assessments after a fall. Resident #4 Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4's clinical record revealed the following: - Activities of Daily Living (ADL) Care Plan dated 12/18/13, documented assist with transfers, one-two persons with gait belt - Post-Fall assessment dated [DATE], indicated the resident attempted to self-transfer while toileting and sustained a fall. - Fall Care Plan dated 12/18/13, documented 1/3/14 tab alarm at all times. - The Interdisciplinary Team (IDT) Summary Post Fall (undated) indicated the resident was confused and nursing placed tab alarm for safety. - Physician order [REDACTED]. - Treatment Records from 1/3/14 through 6/1/14, documented tab alarm at all time to alert staff of unassisted transfers/ambulation. "FYI" (For Your Information) was written beside the order. Nursing staff did not initial daily to document tab alarm was in placed. - Post-Fall assessment dated [DATE], documented the resident attempted to transfer and fell . The staff did not identify if the tab alarm was in placed and working. -The clinical record lacked documented evidence interventions had been evaluated and the Fall Care Plan was not updated. - Post-Fall assessment dated [DATE], documented the resident attempted to use the bathroom independently because staff did not respond in time. The staff did not identify if the tab alarm was in place and working. - The Fall Care Plan dated 6/16/14 documented, tab alarm to bed/wheel chair to alert staff of unassisted transfers. - Physician order [REDACTED]. - The clinical record lacked documented evidence nursing staff ensured tab alarms were in place. - The clinical record lacked documented evidence the resident was not left unattended in the bathroom or was toileted frequently in accordance with facility policy. On 6/17/14 at 9:30 AM, the resident was observed in bed. There was no tab alarm in place and no observable tab alarm in the room. The resident discussed the fall history and most recent fall. The resident indicated an inability to wait for staff to assist for toileting. The resident denied having a tab alarm in place over the past few months. On 6/17/14 at 2:25 PM, a Licensed Practical Nurse (LPN) indicated post fall interventions had been completed. The LPN reviewed the Treatment Record and Care Plan regarding the tab alarm. The LPN indicated nursing staff had not initialed the Treatment Plan regarding the tab alarm. The LPN indicated the Certified Nursing Assistants (CNA) have routinely applied tab alarms and verified their use. The LPN indicated skilled nursing staff have completed Resident Care Assessment to direct the CNA staff. The most recent Resident Care Assessment was kept in a CNA book and was not part of the resident record. On 6/17/14 at 2:30 PM, a CNA who provided care to the resident indicated being unaware the resident should have a tab alarm. The CNA provided the Resident Care assessment dated [DATE], which did not indicate the resident should have tab alarms or required supervision in the bathroom. On 6/20/14 at 11:20 AM, the Director of Nursing indicated when a tab alarm is ordered by the resident's physician staff are to monitor tab alarm placement and usage by initialing every shift on the treatment record. The facility's High Risk for Falls Guidelines, undated, no policy number, documented: "...Assist the resident with all transfers... ...Toilet the resident frequently while aware... ...The resident is not to be left alone in the bathroom."

Based on observation, interview and record review, the facility failed to: 1) promptly assess and intervene for residents experiencing significant changes of condition for 2 of 29 sampled residents (Resident #3 and #10); 2) follow physician orders [REDACTED].#16); 4) ensure the prescribed amount of fluid was given to 1 of 29 sampled residents (Resident #3), and; 5) follow bowel protocol for 1 of 29 sampled residents (Resident #3). Findings include: On [DATE], Employee #3 (Registered Nurse) was asked to provide the policy for the monthly recapitulation of physician orders. An undated paper titled RECAP INSTRUCTIONS was provided and documented the following: "1. Review recap (recapitulation) order with all newly written orders over the last month-make any corrections needed. 2. Compare current recap order sheet to items in the chart.... 3. Compare new MARS (medication administration records) to medications on a. New order sheet b. Old MARS c. All new orders written 4. On new MARS a. Make sure every medication has a time designated, or PRN (as needed) No medication should have a blank space in the "TIME" column...." Resident #16 Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's medical record revealed the following: - A physician progress notes [REDACTED]. - A signed physician order [REDACTED]. - The MAR for [DATE] documented the [MEDICATION NAME] had been discontinued on [DATE]. - The MAR for [DATE] documented the [MEDICATION NAME] had been administered [DATE] through [DATE]. On [DATE] at 9:30 AM, Employee #8 (Licensed Practical Nurse) confirmed the [MEDICATION NAME] had been discontinued on [DATE]. The employee explained the discontinued [MEDICATION NAME] had not been correctly documented during the recap process. The employee acknowledged a medication error had occurred with the [MEDICATION NAME] and it would be corrected immediately with the physician notified of the situation. Resident #1 Resident #1 was admitted on [DATE] and last readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #1's medical record documented the resident was on sliding scale (ss) insulin coverage. Resident #1's physician orders [REDACTED]. - Accucheck q (every) 4 hours with Humalog per ss (sliding scale): - 0 - 250 = 0 units (u); - 251 - 300 = 3 u; - 301 - 350 = 6 u; - 351 - 400 = 9 u; - < (less than)(sic) 401 = 15 u and call MD (medical doctor) - If alert and able to swallow - administer OJ (orange juice) with pkts (packets) of sugar. Recheck blood sugar after 10 min. (minutes); - If blood sugar continues to decrease give [MEDICATION NAME] 1 mg (milligram) IM (intramuscular), SQ (subcutaneous), or IV (intravenous) and notify physician. - [MEDICATION NAME] 1 mg (milligram) emergency kit - [DIAGNOSES REDACTED] There were no blood sugar (BS) parameters listed to indicate when to administer OJ or [MEDICATION NAME]. Resident #1's accucheck coverage sheets documented the following: - Date Time BS Results Intervention - [DATE] 5:00 PM -"HI" - Humalog - 15 u sq; - [DATE] 6:00 PM - "HI" - Recheck; - [DATE] 7:00 PM - "HI" - Humalog - 15 u sq There was no documented evidence the physician was notified of the "HI" BS. - [DATE] 6:00 AM - 77 - OJ with sugar - [DATE] 12:00 AM- "HI" - No documented evidence Humalog Insulin was given - [DATE] 4:00 PM - 74 - OJ - [DATE] 10:00 PM - 91 - OJ - [DATE] 10:00 PM - 548 - Humalog 15 u - [DATE] 8:00 AM - 69 - OJ - [DATE] 8:00 PM - 405 - Humalog 15 u - [DATE] 8:00 PM - 433 - Humalog 15 u - [DATE] 8:00 PM - 520 - Humalog 15 u There was no documented evidence the physician was notified of the high BS results on ,[DATE], ,[DATE], ,[DATE], ,[DATE] and [DATE]. Resident #1's physician recap orders dated [DATE], included: - Accucheck q ac (before every meal) and hs (hour of sleep) with Regular Insulin per ss (sliding scale): - < 250 = 0 u; - 251 - 350 = 2 u; - 351 - 450 = 6 u; - > (greater than) 450 = 10 u and repeat accucheck Resident #1's accucheck coverage sheets documented the following: - Date Time BS Results Intervention - [DATE] - 4:30 PM - "HI" - [MEDICATION NAME] Ins (Insulin) - 15 u - [DATE] - 7:45 PM - "HI" - [MEDICATION NAME] Ins - 10 u - [DATE] - 10:15 PM - "HI" - [MEDICATION NAME] Ins - 10 u - [DATE] - 10:30 PM - "HI" - [MEDICATION NAME] Ins - 10 u The nurse's notes dated [DATE] documented the physician was notified at 4:30 PM, and orders received to administer 15 u Ins. There was no documented evidence the physician was notified Resident #1's BS remained at a "HI" level after 4:30 PM. [DATE] - 14:30 PM - "HI" - [MEDICATION NAME] Ins 10 u [DATE] - 6:30 - "HI" - [MEDICATION NAME] Ins - 10 u There was no documented evidence the physician was notified of Resident #1's "HI" BS. [DATE] - 6:00 AM - 450 - [MEDICATION NAME] Ins - 6 u [DATE] - 6:00 AM - "HI" - [MEDICATION NAME] Ins - 10 u There was no documented evidence the physician was notified of these BS results. [DATE] - 11:30 AM - 58 - No Coverage There was no documented evidence the resident received OJ or [MEDICATION NAME]. [DATE] - 11:30 AM - 550 - [MEDICATION NAME] 10 u sq There was no documented evidence the physician was notified. Resident #1's physician orders [REDACTED]. - Accucheck q (every) 4 hours with Regular Insulin per ss (sliding scale): - < 250 = 0 units (u); - 251 - 350 = 2 u; - 351 - 450 = 6 u; - > 450 = 10 u and repeat accucheck The sliding scale coverage for Resident #1 was changed to ac & hs (before meals and at bedtime) as of [DATE]. Resident #1's accucheck coverage sheets documented the following: - [DATE] - 10:00 PM - 596 - Humalog - 6 u - [DATE] - 12:00 AM - 401 - No Insulin - [DATE] - 10:30 AM - "HI" - Regular Insulin - 10 u - [DATE] - 2:30 PM - 500 - Regular Ins - 10 u - [DATE] - 10:00 PM - 524 - No Insulin - [DATE] - 6:00 AM - "HI" - Regular Ins 10 u - [DATE] - 4:00 PM - 337 - Recheck - No Insulin - [DATE] - 10:00 PM - "HI" - Reg Ins 10 u - [DATE] - 2:00 AM - "HI" - Regular Ins 10 u - [DATE] - 6:00 AM - "HI" - Recheck - No Insulin There was no documented evidence the physician was notified regarding Resident #1's elevated BS levels. The facility policy titled [DIAGNOSES REDACTED], undated documented: - "Purpose: To provide immediate corrective interventions when the blood glucose level of a resident falls into a critically low range (60 mg/dl(deciliter)), or when signs and symptoms of impending hypoglycemic shock are present. - Policy: If the resident does not respond to oral interventions to raise the blood glucose level, the nurse will administer [MEDICATION NAME], 1 mg. I.M., S.Q., or I.V.. May repeat in 15 minutes if needed. Always call the physician to update on resident condition." The facility policy titled Physician Notification Parameters Guidelines undated, documented: - "Purpose: To provide licensed nursing staff of general guidelines for situations under which a physician should be notified....Laboratory values - Chemistry ...Immediate - Glucose: > 300 in diabetic with no s/s (signs and symptoms); >430 in diabetic with s/s." The manufacturer's guidelines for the Accucheck machine used by the facility indicated a "HI" reading indicated a Blood Sugar level > 600. On [DATE] in the afternoon, the Director of Nursing (DON) verbalized the physician should be notified of the high blood sugar readings. The DON confirmed the lack of documentation on the accucheck coverage sheets. Resident #3 Resident #3 was admitted on [DATE], with [DIAGNOSES REDACTED]. a) On [DATE] at 2:44 PM, Resident #3 was observed with fast, labored breathing with clear secretions draining from the mouth. The inspector notified Employee #12 about Resident #3's condition. The employee acknowledged plans to notify the physician of the resident's condition. On [DATE] at 3:40 PM, Resident #3 was noted to be breathing faster than previously observed. At that time, the inspector notified Employee #12 of the resident's respiratory status. The employee explained Resident #3's attending physician was notified because the oxygen saturation was 84%. The physician ordered the resident be transferred to an acute care emergency room . On [DATE] at 3:45 PM, the inspector requested Employee # 13 re-check Resident #3. The employee reported the resident's oxygen saturation was 70% (percent) and the heart rate was 120 beats per minute. The inspector asked Employee #13 when the resident would be transported to the emergency room . The employee said "I will call the ambulance right now." On [DATE] at 4:04 PM, paramedics arrived at Resident #3's room. At 4:15 PM, the resident was transported to the emergency room . On [DATE] at 5:00 PM, Employee #13 explained Employee #12 reported Resident #3 was coughing during the morning and the oxygen saturation was 88%. Employee #13 affirmed a call was placed at 3:45 PM, after the resident's vital signs were re-checked, requesting non-emergency ambulance transportation services. According to the employee, the non-emergency ambulance service activated 911 due to Resident #3's condition. Resident #3's record revealed a nurse's note dated [DATE], documented the resident was observed coughing at 9:00 AM. The nurse's notes indicated the resident was "getting more congested" at 2:45 PM and oral suction was performed. The nurse's note documented the resident's attending physician was notified at 3:00 PM. The physician ordered the resident transferred to an acute care setting for evaluation. On [DATE] at 5:15 PM, the Director of Nursing (DON) explained 911 should be called immediately if a resident was experiencing a life-threatening condition. Resident #3's record lacked documented evidence an ongoing assessment was performed on the resident due to the change of condition. b) Review of Resident #3's Bowel Record dated [DATE], revealed the resident had a bowel movement (BM) on [DATE]. The record documented Resident #3 did not have a BM for five consecutive days, from [DATE] to [DATE]. Resident #3's record documented the following physician orders [REDACTED]. - "... Milk of magnesia (MOM) 30 cc (cubic centimeter) via [DEVICE] QD (daily) PRN (as needed) for constipation. - [MEDICATION NAME] suppository 10 mg (milligram) PR (per rectum) QD PRN if MOM is ineffective. - Fleet enema on evening shift if [MEDICATION NAME] suppository ineffective after 24 HRS (hours). - SSE (soap suds enema) on evening shift if Fleets enema ineffective after 1 hour. - If SSE eneffective (sic) call MD (medical doctor)..." Resident #3's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] during the afternoon, the DON explained if a resident did not have a BM in 3 days, a BM protocol should be implemented, beginning with the administration of MOM. Facility policy titled Bowel Regimen Protocol revised [DATE], read: "... 2. MOM 30 CC (Milk of Magnesium)- indicate route a. On a day shift if no bowel movement after (3) days... 3. [MEDICATION NAME] suppository PRN on evening shift if MOM ineffective by the next shift. a. Fleet enema on evening shift if [MEDICATION NAME] suppository ineffective after 2 H (hours). b. Soap suds enema on evening shift if Fleets enema ineffective after (1) hour. 4. Notify the physician if the above measures are ineffective". c) Review of Resident #3's record revealed a physician order [REDACTED]. "... - [MEDICATION NAME] 1.2 @ (at) 75 ml/HR (milliliter per hour) X (times) 20 HRS - Formula intake for 24 HRS total = (equal) (1500) cc/day - Formula per shift ,[DATE] shift (600) cc - Formula per shift ,[DATE] shift (300) cc - Formula per shift ,[DATE] shift (600) cc - H2O (water) flush 500 cc Q6H (every 6 hours)" Dietary Progress Notes dated [DATE], read: "... H2O flush 500 ml q 6 ? (every 6 hours)..." Resident #3's Monthly Intake and Output record for May and [DATE], lacked documented evidence of the total amount of fluids given to the resident. On [DATE] at 4:00 PM, Employee #5 explained the fluid intake had to be documented in the corresponding column on the Monthly Intake and Output form and totaled at the end of the shift. The employee stated nurses also documented the intakes in the MAR. On [DATE] at 4:26 PM, Employee #12 affirmed water flush are provided in [MEDICATION NAME] of 250 ml in different moments during each shift and not 500 ml every 6 hours as ordered. Laboratory report dated [DATE], revealed the out of range blood parameters including: - BUN (blood urea nitrogen): 96 mg/dL (milligram per deciliter). Reference range: ,[DATE] mg/dL. - Creatinine: 1.9 mg/dL. Reference range: 0.6- 1.3 mg/dL. - eGFR (estimated Glomerular Filtration Rate): 38. Reference range: 60- 499. -Potassium: 5.5 meq/L (milliequivalents/liter). Resident #3's record revealed a physician dated [DATE], that read: "... - IVF (intravenous fluids) - 0.9 Normal saline @ 70 cc/hr (cubic centimeter per hour) X 2 Liters... ? (High) BUN..." Resident #3's physician order [REDACTED]. "... - Cont. (continue) IVF 0.9 NS (normal saline) 1 L (liter) @ 70 cc/hr X 5 more liters..." Resident physician order [REDACTED]. "... Give IVF ? (half) NS @ 70 cc/hr X 5 Litters (sic) After the current order of IVF..." Review of Resident #3's record revealed resident was transferred to an acute care emergency department on [DATE], due to electrolyte imbalance. Resident #10 Resident #10 was admitted on [DATE], with [DIAGNOSES REDACTED]. On [DATE] at 8:00 AM, Resident #10 was in the bed unresponsive. The Director of Nursing and Employee #12 were also in the resident's room. On [DATE] at 8:08 AM, the paramedics arrived and started evaluating Resident #10's vital signs. Paramedics confirmed Resident #10's blood pressure (B/P) was ,[DATE] millimeters of Mercury (mmHg). The oxygen saturation could not be determined and the glucometer indicated a "low" blood sugar level. On [DATE] at 8:14 AM, Resident #10 stopped breathing and Employee #12 started resuscitating the resident using a self-reinflating resuscitator bag to provide respiratory support. On [DATE] at 8:25 AM, the paramedics transported Resident #10 to an acute care emergency department. On [DATE] at 9:10 AM, Employee #12 explained a Certified Nursing Assistant (CNA) reported Resident #10 was unresponsive in bed around 06:30 AM. At that time, Employee #12 checked the resident's vital signs with the following results: B/P ,[DATE] mmHg, pulse 81 beats per minute (BPM), an oxygen saturation of 93% -95%. The employee said Resident #10 was checked again at 07:35 AM and remained unresponsive. Employee #12 further explained oxygen was applied to Resident #10 at 3 liters per minute via nasal cannula. The employee's attempted to call the physician at 7:40 AM. The call was unanswered. The employee affirmed the resident's daughter was called to get consent to send the resident to the emergency department. Resident #10's Categorization Status dated [DATE], revealed the resident was Category I, with interventions including maximum therapeutic effort to be made without limitations, cardio [MEDICAL CONDITION] resuscitation (CPR) and transfer to acute hospital. On [DATE] at 10:50 AM, the DON explained nurses should not call family members to get consent to transfer the resident to an acute care hospital if the resident was category I and was experiencing a life-threatening condition. Facility's undated Policy titled Physician Notification Parameters, read: "...Purpose: To provide licensed nursing staff of general guidelines for situations under which a physician should be notified... Condition... Immediate... Abrupt change in mental status... 1. The nurse should not hesitate to contact the physician at anytime for a problem which in their judgment requires immediate medical attention... Implementation... d. For situations requiring immediate action, use the best clinical judgment."

Based on interview, clinical record review, and document review, the facility failed to ensure residents were provided with sufficient fluid to maintain proper hydration for two of 5 sampled residents (Resident #3 and #4). Findings include: The facility's policy entitled, Hydration (not dated) documented the purpose of the policy was to ensure liquids were offered to residents in order to provide adequate hydration. The policy revealed a glass of water was to be offered to all residents who were able to consume oral fluids at least every two hours during the 7:00 AM -3:00 PM shift and 3:00 PM-11:00 PM shift. The 11:00 PM -7:00 AM shift indicated staff were to offer a glass of water to residents who awoke during the night and to residents as they arose in the morning. Resident #3 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation entitled Initial Nutritional assessment dated [DATE], revealed Resident #3's height was 63 inches and weight 117 pounds or 53.1 kilograms. The estimated nutritional caloric needs was documented as 1330-1600 calories per day, and Fluids 1600 cc. Problem/Needs/Concerns included: at risk for weight loss secondary to poor oral intake. The approaches included encourage increase oral intake/fluids, assist with meals, monitor weight trends/oral intake and recommend Med pass 2.0 four ounces three times a day. The goal was the resident will remain adequately nourished/hydrated with no significant weight loss. The clinical record lacked documentation the Registered Dietician (RD) had re-assessed the resident's hydration status after the initial assessment. There was no documentation the RD was aware the resident had not been receiving the estimated fluid amount. Review of the room appetite log indicated from 1/18/13 through 1/14/13 Resident #3 consumed approximately 240-600 milliliter (ml/cc) of fluid each day with her meals. The Registered Dietician (RD) calculated the estimated fluid needs as 1600 cc a day. The clinical record documented Resident #3's vital signs as follows: On 12/15/12, temperature 97.9, blood pressure 124/70, pulse 68, respirations 18. On 12/22/12, temperature 98.1, blood pressure 120/68, pulse 62, respirations 18. On 12/29/12, temperature 98.0 , blood pressure 118/72 , pulse 66, respirations 18 . On 1/5/13, temperature 97.8, blood pressure 106/68, pulse 71, respirations 18. On 1/13/13, at midnight, the nurse notes documented the resident was observed to be non-responsive, color pale, vital signs: blood pressure 89/48 (normal blood pressure less than 120 mm Hg (millimeters of mercury) systolic and less than 80 mm Hg diastolic pressure), pulse rate 121 (normal rate 60-100 beats per minute), respiratory rate 20 (normal rate 15-20 breaths per minute), temperature 100.9 ( normal body temperature from 97.8 degrees Fahrenheit to 99 degrees Fahrenheit), oxygen saturation 96% (normal 95%-100%). Tylenol 500 mg given and Head of Bed (HOB) was elevated. A nurses note dated on 1/14/13 at 2:00 AM, documented Resident #3's oxygen saturation 90%, blood pressure 104/65, pulse rate of 120, respiratory rate 20, temperature 99.1. The resident was non responsive, head of bed elevated. Plan to monitor. A nurses note dated 1/14/13 at 4:00 AM, documented temperature 101.1, blood pressure 95/65, pulse rate of 112, respiratory rate 18, oxygen saturation 90%, Tylenol 500 mg given. Taking fluids poorly. Plan to monitor. On 1/14/13 at 7:00 AM, a nurses note documented Resident #3 was semi-alert, opens eyes, non verbal, oxygen saturation 80%. Refused breakfast and fluids. Temperature 99.1 degrees Farenheit (F). On 1/14/13 at 8:45 AM, a nurse note documented temperature 102.1, oxygen saturation via mask 83%, pulse rate 102, blood pressure 100/80, non responsive at this time. Physician called. The resident's family was contacted on 1/14/13 at 9:00 AM. On 1/14/13 9:15 AM, the nurses notes documented 911 on unit. The resident will be transferred to hospital Emergency Department. The resident was sent to the hospital emergency room . The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 3/25/13 at 1:26 PM, the Assistant Director of Nursing (ADON) indicated the signs and symptoms of dehydration were dry mucus membranes, poor skin turgor, sunken eyes, confusion and decrease urinary out put. The ADON revealed with dehydration the Blood Urea Nitrogen (BUN), Sodium and Creatinine would be elevated and the Potassium would be low. The ADON verbalized the resident's vital signs would show decreased blood pressure, increase pulse rate, respiratory rate and the resident would be "running at temperature." The ADON revealed the nurse's notes dated 1/13/13, at midnight indicated the resident was dehydrated and had a change of condition. The ADON verbalized the nurse's note dated 1/14/13 at 2:00 AM, revealed the oxygen saturation was down, the pulse rate was "very high" and the resident was showing signs and symptoms of dehydration. The ADON verbalized the nurses note dated 1/14/13 at 4:00 AM, indicated the resident was "rapidly declining, a severe change in condition and not improving." On 3/28/13 a Licensed Nurse (LN) reviewed the Room Appetite Report for January 2013. The LN revealed the average oral intake from 1/8/13 to 1/14/13 was approximately 600 cc/ml of fluid. The LN stated, "It doesn't look like the fluids were met". On 3/28/13 at 10:28 AM, the Director of Nursing (DON) revealed other than the resident's who were on intake and output there was no documentation fluids were offered every 2 hours according to the hydration policy. The DON confirmed there was no documentation to indicated the resident had been offered fluids per the hydration policy. On 4/9/13 at 7:00 AM, the Registered Dietician (RD) verbalized when a Nutritional Assessment was done she would physically look at the resident if they were in the room, check the meal percentage sheets, check the Medication Administration Records, Intake and Output form and interview the resident. The RD verbalized sometimes she spoke with the nurses about the residents intake and how the resident was eating at meal time. The RD verbalized this information would be documented in the RD progress notes. The RD revealed the signs and symptoms of dehydration were poor skin turgor, poor urine output, gray color, increased heart rate and decreased blood pressure. The RD revealed a resident could become dehydrated in a few days During the interview on 4/9/13, the RD revealed Resident #3's estimated daily fluid intake was 1600 cubic centimeters (cc) or milliliters (ml). The RD confirmed from the nurses notes Resident #3 was dehydrated. The RD indicated her documentation in the RD notes did not reflect the resident had not received adequate fluids. The RD indicated "I guess I was not aware , I don't have that documented." The Emergency Department (ED) documentation dated 1/14/13, documented the resident had a long standing history of dementia and over the past few weeks had been unable to provide herself with nutrition or hydration herself. The family verbalized as far as they know the resident had not been having vomiting or diarrhea but had not had any intake of any fluids over the past few weeks, as her dementia had progressed and she had not been feeding herself or providing herself with hydration. The Consultation Report dated 1/14/13, the resident received 100-200 cc normal saline in the ED for volume resuscitation until it was noted the resident had [MEDICAL CONDITION] (increased sodium level) and it was stopped. Assessment and Plan: 1. Acute kidney disease. The resident will be [MEDICATION NAME] with 500 cc 1/2 normal saline at 110 cc/ml per/hour. 2. Hypovolemic hypernatermia: Secondary to poor free water intake. Physical examination included: heart rate 88, respiratory rate 41 and the blood pressure 101/72. The documentation revealed the laboratory results were as follows: Sodium "very high" at 173 (normal reference range 136-145 Millimole/Liter) Potassium 3.8 (normal reference range 3.5-5.0 Millimole/Liter) Chloride 134 (normal reference range 98-11 Millimole/Liter) BUN 74 ( normal reference range 5-20 milligrams/deciliter, /g/dl) Creatinine 3.08 (normals reference ranged 0.50-1.50 mg/dl) BUN/creatinine ratio 24 (normal range 10-20) Lactic acid was "very high" at 3.25 (Venous blood: 4.5-19.8 mg/dl and Arterial blood: 4.5-14.4 mg/dl). Assessment Acute [MEDICAL CONDITION] secondary to what appears to be dehydration, [MEDICAL CONDITION] critical, pneumonia,[MEDICAL CONDITION] with elevated [MEDICATION NAME], history of dementia, and behavioral changes. Resident #4 Resident #4 was admitted to the facility on [DATE] from the acute care hospital with [DIAGNOSES REDACTED]. Documentation entitled Initial Nutritional assessment dated [DATE], indicated the resident's height was 65 inches, weight 127 pounds. The estimated Nutritional Needs: Calories: 1730 and Fluid: 1730 cc. The resident had a stage 3 pressure ulcer, the resident's appetite was 25-50% of meals and the resident required assistance with meals. The Problems/Needs/Concerns: Poor oral intake. Resident will remain adequately nourished/hydrate with no significant weight loss. Encourage oral intake, monitor weight trends, oral intake and laboratory results. The Room Appetite Report dated January 2013 revealed blank areas for the documentation of the fluid and meals consumed for breakfast, lunch and dinner on 1/22/13, and blank areas for the documentation of meal and fluid intake for the dinner meal on 1/23/13, 1/24/13 and 1/27/13 through 1/31/13. The Monthly Intake and Output forms dated January 2013 lacked documented evidence on the Intake and Output form Resident #4's fluid intake for the entire day on 1/22/13, no documented fluid intake on evening shift on 1/23/13 through 1/28/13. There was no documented intake of fluid on the night shift on 1/23/13 and 1/25/13 through 1/31/13. According to the documentation during the month of January 2013 the resident had not meet the estimated fluid intake requirement of 1730 cc/ml per day. The Room Appetite Report dated February 2013 revealed blank areas for the documentation of the fluid and meal consumed on 2/10/13. The documentation revealed the resident had not consumed fluids or solids for breakfast on 2/22/13, 2/23/13, 2/25/13, 2/26/13, 2/27/13 and 2/28/13. The documentation revealed the resident had not consumed solids for lunch on 2/26/13, 2/27/13 and 2/28/13. The Room Appetite Report documented the resident did not consume solids or fluids for dinner on 2/24/13 and 2/27/13. The Monthly Intake and Output forms dated February 2013 lacked documented evidence on 2/1/13, 2/9/13, 2/14/13 of fluid intake for the entire day. There was no documented evidence the resident had received fluids on the evening shift on 2/2/13, 2/3/13, 2/4/13, 2/6/13 through 2/8/13, 2/10/13, 2/11/13, 2/15/13. There was no documented evidence Resident #4 had received fluids on the night shift on 2/2/13 through 2/8/13, 2/10/13 thorough 2/13/13 and 2/15/13. The February Intake and Output record lacked documentation the resident's output had been documented on the day shift on 2/1/13, 2/9/13 and 2/14/13. There was no documented evidence the resident's output had been measured on the the evening shift on 2/8/13, 2/11/13, 2/14/13, and 2/15/13. There was no documentation the resident's output had been measured on 2/3/13, 2/4/13, 2/10/13, 2/11/13 and 2/15/13. The clinical record lacked documentation the RD had re-assessed the resident's hydration status after the initial assessment. There was no documentation the RD was aware the resident had not been received the estimated daily fluid amount. The resident Transfer Form dated 2/16/13 documented the resident was in the dining room and fell forward in her chair non responsive. Taken to room for evaluation. Slightly responsive-respirations weak, checked vital signs blood pressure 160/84. Called 911 for transport. Left facial droop with drooling. Pulse rate 80, respirations 13 and mental status confused. On 4/9/13, the RD revealed Resident #4 had a history of [REDACTED]. The RD indicated the Intake and Output record had a lot of hole (blank areas). The RD revealed according to the Intake and Output record the resident had not bee getting enough fluid. The RD verbalized she had not been aware of this, she had been looking at the laboratory results. The RD indicated the RD note did not reflect the resident's hydration outside of the Med pass. The RD revealed some intervention that could be done to increase fluid in take were a resident could be offered fluids by the Certified Nursing Assistant (CNA), the nurse can offer fluids and the resident had water pitchers in their rooms.