Every finding on record at Ormsby Post Acute Rehabilitation

Based on observation, interview, and document review, the facility failed to ensure 1) proper hand hygiene was performed by dietary staff, 2) refrigerated food was stored properly, 3) food was discarded by the expiration date, and 4) the outside propane gas grill (Barbecue) was cleaned appropriately. This deficient practice had the potential to affect all residents in the facility by increasing the risk of infection and foodborne illnesses. Findings include: Hand Washing On 05/11/2026 at 8:31 AM, a Dietary [NAME] was holding a baking pan containing potatoes. The Dietary [NAME] was not wearing gloves. The Dietary [NAME] place the baking pan onto the food preparation surface and donned gloves without performing hand hygiene. On 05/13/2026 at 11:40 AM, the Dietary [NAME] was holding a baking pan containing chicken. The Dietary [NAME] was not wearing gloves. The Dietary [NAME] place the baking pan onto the food preparation surface and donned gloves without performing hand hygiene. On 05/14/2026 at 9:24 AM, Dietary [NAME] was holding a baking pan containing carrots. The Dietary [NAME] was not wearing gloves. The Dietary [NAME] place the baking pan onto the food preparation surface and donned gloves without performing hand hygiene. The Dietary [NAME] picked up a ladle and continued to stir soup on the adjacent stove. On 05/11/2026 at 9:00, the Dietary Supervisor confirmed staff were required to perform hand hygiene when donning gloves and changing gloves. The Dietary Supervisor explained staff were required to wear gloves to prevent transmitting illness to residents Food Storage On 05/11/2026 at 8:45 AM, in the walk-in refrigerator, a shrink-wrapped cooked ham was stored in a bin on the bottom shelf. Raw pork chops were stored in a plastic bag placed atop the ham. The ham shrink wrap was in contact with the pork chop bag. On 05/11/2026 at 8:50 AM, the Dietary Supervisor confirmed the ham and pork chops should be stored separately in different bins and stated improper storage could result in resident illness. Expired Food On 05/11/2026 at 9:02 AM, in the walk-in refrigerator, a metal hotel pan of caramel sauce was sealed with plastic wrap. Exp. 05/08/2026 was written on the plastic wrap. On 05/11/2026 at 9:08 AM, the Dietary Supervisor confirmed the caramel sauce should have been discarded and stated the refrigerator was checked daily. Barbecue Grill On 05/11/2026 at 9:17 AM, a barbecue grill located at the back of the facility was open, revealing the interior grate covered in layers of char and grease. On 05/11/2026 at 9:18 AM, the Dietary Supervisor confirmed the barbecue grill should have been cleaned after use. A facility policy titled Food Safety Requirements, implemented 04/11/2025, staff shall not touch food with bare hands and exhibit appropriate use of gloves, tongs, deli paper, and spatulas. Food should be stored in a manner to prevent the deterioration or contamination of the food, including the growth of microorganisms. Refrigerated food should be used, frozen, or discarded as applicable by the use-by-date. All equipment used in the handling of food shall be cleaned, sanitized and handled in a manner to prevent contamination.

Based on observation, interview, record review, and document review, the facility failed to ensure the data collected for infection surveillance was used to identify the potential cause of facility acquired infections and prevent further facility acquired infections for 5 of 5 months reviewed for 2026. This deficient practice had the potential to result in residents contracting preventable infections and poor infection control practices continuing due to a lack of targeted education provided to facility staff.Findings include: The 2026 Infection Surveillance spreadsheets documented the following facility acquired infections: January 2026 had two corona virus (Covid) infections, two eye infections, 13 urinary tract infections, eight cases of pneumonia, seven fungal/yeast infections, one case of cellulitis, one respiratory illness, one ear infection, and one wound infection. February 2026 had six urinary tract infections, two cases of pneumonia, one case of shingles, seven yeast infections, two cases of cellulitis, and one case of a clostridium difficile (C. diff) infection. March 2026 had five skin rashes, two cases of cellulitis, two wound infections, five yeast infections, two eye infections, one urinary tract infection, one case of dermatitis, and one case of pneumonia. April 2026 had four respiratory infections, four yeast infections, two oral abscesses, four cases of pneumonia, two cases of cellulitis, three skin rashes, four cases of C. diff, one wound infection, three urinary tract infections, and one skin infection. May 2026 for the period of May 1, 2026, through May 14, 2026, had two wound infections, five urinary tract infections, two yeast infections, and one case of rheumatic fever. On 05/14/2026 at 1:09 PM, the Infection Preventionist verbalized the facility had not provided education to staff specific to the data collected from the infection surveillance and the facility had not analyzed the data to determine the cause of the facility acquired infections. The facility policy titled Infection Prevention and Control Program, dated 04/11/2025, documented a system of surveillance would be utilized for prevention, identification, investigating, and controlling infections and communicable diseases for all residents and staff. The Infection Preventionist would maintain documentation of incidents, findings, and any corrective actions made by the facility and report surveillance findings to the facility's Quality Assessment and Assurance Committee.

Based on personnel record review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) employed for more than one year had an annual performance review completed annually for 1 of 4 CNAs reviewed for completed performance reviews (Employee #9). This deficient practice had the potential to affect all residents when the facility did not identify areas of CNA performance in need of in-service education or training. Findings include:Employee #9Employee #9 was hired by the facility on 11/04/2025, as a CNA.Employee #9's personnel record documented a performance review completed on 11/14/2024.On 05/13/2026 at 2:46 PM, the Human Resource Coordinator (HRC) verbalized all CNAs were required to have a performance review completed by the CNAs anniversary date and confirmed Employee #9's performance review was completed 10 days late.On 05/14/2026 at 10:24 AM, the Administrator verbalized the facility did not have a policy related to CNA performance reviews; however, the facility followed all federal regulations.

Based on interview, record review, and document review, the facility failed to ensure a resident was provided with education related to the common side effects and treatment purpose of a psychotropic medication prior to the resident receiving the medication for 2 of 19 sampled residents (Residents #5 and #64). This deficient practice had the potential for a resident to receive medication without the resident having had the opportunity to make an informed decision regarding the medication prior to receiving the medication. Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including bipolar disorder, current episode manic severe with psychotic features and anxiety disorder, unspecified. The Order Summary Report for Resident #5 documented an order for quetiapine fumarate oral tablet 300 milligrams (mg). Give one tablet by mouth one time a day for manic depression. The order start date for the medication was 03/12/2026. A Psychotropic Medication Consent for quetiapine 300 mg every day, documented consent was provided by the resident's representative on 04/21/2026. A Medication Administration Record (MAR), dated March 2026, documented the resident received a quetiapine 300 mg oral tablet once a day starting on 03/12/2026. On 05/13/2026 at 11:38 AM, the Chief Nursing Officer (CNO) verbalized the psychotropic medication consent was not completed before the psychotropic medication was started. The CNO verbalized the resident's representative should have been given the opportunity to consent or refuse the medication before the medication was administered to the resident. Resident #64 Resident #64 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including schizoaffective disorder, bipolar type, personality disorder, unspecified, dissociative and conversion disorder, unspecified, and major depressive disorder, recurrent, unspecified. A Physician's Order dated 01/21/2026, documented olanzapine oral tablet 5 mg. Give one tablet by mouth one time a day for schizoaffective disorder related to schizoaffective disorder, bipolar type, schizoaffective disorder, unspecified, personality disorder, unspecified, dissociative and conversion disorder, unspecified and major depressive disorder, recurrent, unspecified. Resident #64's January, February and March 2026 MARs documented the olanzapine was administered once daily from 01/21/2026 through 03/30/2026, with the exception of one dose not administered on 02/01/2026. Resident #64's clinical record lacked documented evidence a Psychotropic Medication Consent was completed. On 05/12/2026 at 1:32 PM, the Director of Nursing (DON) verbalized staff were required to obtain consent prior to administration of psychotropic and opiate medications. The consent was used to inform the resident about the risks and benefits of the medication and to explain the medication to the resident. The DON verbalized Resident #64 had several consents in the resident's record due to several psychotropic medications being ordered and the DON would have to look for the consent related to olanzapine. On 05/12/2026 at 3:00 PM, the Assistant DON (ADON) reviewed Resident #64's January 2026 MAR and acknowledged the medication was administered to the resident. The ADON verbalized the ADON was attempting to locate the consent for the medication. On 05/13/2026 at 12:37 PM, the CNO verbalized facility staff had reviewed all records and the facility did not have an informed consent for Resident #64 prior to administration of olanzapine. The CNO confirmed a consent should have been obtained prior to administration of the medication. The facility policy titled Use of Psychotropic Medication(s), last reviewed/revised 04/28/2025, documented a psychotropic drug was any drug which affected brain activities associated with mental processes and behavior. Psychotropic drugs included but were not limited to antipsychotics, antidepressants, anti-anxiety and hypnotics. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative was to be informed of the benefits, risks and alternatives for the medication including any black box warnings. The resident had the right to accept or decline the initiation or increase of the medication. The facility would document the resident or representative was informed in advance of the risks and benefits of the proposed care, treatment alternatives or other options, and the preferred option to accept or decline in a format the facility deemed to use (e.g., written consent form, narrative note, etc.). The facility document titled Resident Rights, undated, documented residents had the right to make their own choices, the right to request, refuse, and/or discontinue any treatment, and the right to complete information about their medical condition and treatment. If the resident refused treatment, the facility was required to tell the resident what could happen because of the refusal and tell the resident about other possible treatments.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's right to make choices about aspects of life in the facility that were significant to the resident, by not providing an appropriate wheelchair that would allow the resident to get out of bed, for 1 of 19 sampled residents (Resident #3). This deficient practice had the potential to cause psychosocial distress to the resident. Findings include:Resident #3Resident #3 was admitted to the facility on [DATE], with diagnoses including paraplegia, unspecified, adult failure to thrive, and atherosclerotic heart disease of native coronary artery without angina pectoris.On 05/11/2026 at 12:29 PM, Resident #3 was lying in bed. Next to the bed was a manual wheelchair with plastic wrap around each one of the wheels. The wheels did not have any markings indicating the wheelchair had been used.The resident verbalized the facility provided the wheelchair and has never used the wheelchair. The resident explained the resident did not have enough core strength, as a result of paraplegia, and could not sit in the wheelchair safely. The resident wished to be able to leave the resident's room daily and go outside to enjoy the sunshine. The resident verbalized staff had not gotten the resident out of bed, nor offered to get the resident out of bed, since admitting to the facility. The resident verbalized feeling like it was an act of congress for the facility to acknowledge the resident's requests.Activities care plan, initiated on 04/09/2026, documented the resident had independent hobbies and interest and would need assistance to and from activities. The goals for the resident were for the resident to attend one physical activity to decrease the resident's depression, increase the resident's energy, and maintain the resident's health. The activities would be monitored for the resident's satisfaction with the resident's leisure choices and encourages for the resident to participate in an activity of interest.On 05/12/2026 at 2:07 PM, the Activities Director explained each resident would be asked what types of activities they would like to participate in upon admission to the facility. Residents would be able to go outside and sit on the patio if the resident preferred. If a resident needed assistance to go outside, staff would help the resident out of bed and outside per the resident's preference.The Activities Director verbalized Resident #3 had a wheelchair in the resident's room and believed the resident had never used the wheelchair to the Activity Director's knowledge and confirmed the resident had not left the resident's room since admission.On 05/12/2026 at 2:18 PM, a Registered Nurse (RN) verbalized not seeing Resident #3 come out of the resident's room since being in the facility and was not aware the resident could not use the wheelchair provided.On 05/13/2026 at 10:25 AM, the Social Worker verbalized not having any conversations with Resident #3 and admitted to not initiating any assessments nor providing support for the resident. The Social Worker explained not having met the resident to date and did not know if the resident had any requests, preferences needing to be honored, nor knew what the resident wished to do while in the facility.On 05/14/2026 at 10:27 AM, Resident #3 verbalized not having met the Social Worker and was not holding the resident's breath waiting either.On 05/14/2026 at 9:53 AM, the Director of Nursing (DON) explained Resident #3 was on hospice care and needed assistance with all Activities of Daily Living (ADLs). Staff would need to use a Hoyer lift to get the resident out of bed and place the resident in a wheelchair. The DON verbalized the resident had a wheelchair and was unaware why the resident had not used the wheelchair to date. The DON explained the resident had paraplegia and the resident would not be able to safely use the manual wheelchair provided and would need to be provided a wheelchair with reclining capabilities so the resident would not fall.The DON confirmed the resident's wheelchair was not safe for the resident and the facility had not provided the resident with a safe wheelchair to allow the resident to leave their room. The DON confirmed the resident had not left their room since admission. The DON explained the facility was a homelike environment and all residents' requests and preferences for residents needed to be honored.The facility policy titled Safe and Homelike Environment, last revised 09/02/2025, documented residents had the right to a safe, clean, comfortable, and homelike environment, and to receive services maximizing residents' independence.The facility policy titled Residents' Rights, undated, documented residents had the right to make their own choices, and the facility must treat the resident with respect, dignity, and must care for the resident to promote quality of life. The resident must not be abused, neglected, or exploited by anyone.Cross reference with Tag F600.

Based on interview, clinical record review and document review, the facility failed to ensure 1 of 19 sampled residents (Resident #97) was protected from resident-to-resident physical abuse. This deficient practice had the potential to result in pain, physical injury and mental anguish to residents.Findings include:Resident #97Resident #97 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pleural effusion, not elsewhere classified and chronic respiratory failure with hypoxia.Resident #81Resident #81 was admitted to the facility on [DATE], with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris and chronic obstructive pulmonary disease, unspecified.On 05/11/2026 at 8:58 AM, Resident #97 recalled having trouble with a prior roommate. The roommate would not allow Resident #97 to turn the light on long enough to use the urinal and kept turning the light off. Resident #97 verbalized the roommate hit Resident #97 in the face with a closed fist. Afterward, Resident #97 grabbed the roommate by the shirt and hit the roommate back. Resident #97 denied any resulting injuries from the altercation; however, verbalized the resident no longer trusted the roommate and didn't want to go to sleep as Resident #97 was afraid the roommate would stick a knife in the resident's chest. The incident occurred less than one month prior, and Resident #97 had not seen the roommate following the incident.A final Facility Reported Incident (FRI) report submitted by the facility on 05/03/2026, documented Resident #97 and Resident #81, roommates at the time of the incident, punched each other. On 04/30/2026 at approximately 9:30 PM, Resident #97 was repeatedly screaming when Resident #81 got up and struck Resident #97 in the head. Resident #97 then struck Resident #81 in the head/face region. Both residents were interviewed and admitted to hitting one another.A progress note dated 05/03/2026, documented Resident #97 got into a physical altercation with the resident's roommate on 04/30/2026. Resident #97 utilized the call light to ask for assistance with the urinal. The Certified Nursing Assistant (CNA) turned on the light on Resident #97's side of the room. Resident #97 wanted all the lights to be turned on. The CNA explained the CNA could only turn on the light on the resident's side of the room as the roommate was sleeping. Resident #97 became upset and started yelling. The CNA explained staff and the resident needed to be respectful and quiet as the resident's roommate was sleeping. Resident #97 stopped yelling and finished using the urinal. The CNA was in another resident room when the CNA heard Resident #97 yelling out again. As the CNA approached the room the CNA heard Resident #97 say the roommate hit Resident #97. Upon entering the room, the CNA observed the roommate standing over Resident #97's bed with a clenched fist and the light was turned off. Both residents were engaging in verbal aggression toward each other.On 05/13/2026 at 3:14 PM, the DON verbalized abuse could be mental, sexual, physical, or verbal and caused a negative reaction by the resident, caused the resident to feel upset or affected the resident's emotions in a negative way. Physical abuse would include moving a resident and leaving a bruise, striking a resident and kicking a resident.On 05/14/2026 at 8:23 AM, the DON recalled Resident #97 had a confrontation with the resident's former roommate, Resident #81. The DON explained Resident #97 often refused to use the call light and had behaviors of yelling out to get what the resident wanted. At the time of the incident, Resident #97 needed to use the urinal and the CNA turned on the light on Resident #97's side of the room. The CNA explained Resident #81 was sleeping so the CNA could not turn on all the lights in the room, Resident #97 agreed and used the urinal. While assisting with other residents the CNA heard Resident #97 yelling out. As the CNA approached the room, the CNA heard Resident #97 say Resident #81 hit Resident #97. The CNA saw Resident #81 standing over Resident #97's bed with a closed fist. The DON confirmed the DON helped to complete the investigation of the incident and recalled Resident #81 admitted to hitting Resident #97. Resident #81 claimed the resident reacted to being hit by Resident #97 first.The facility policy titled Abuse, Neglect and Exploitation, dated 04/11/2025, documented abuse was the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish which could include staff to resident abuse and certain resident to resident altercations. It included verbal abuse, sexual abuse, physical abuse, and mental abuse. Physical abuse included but was not limited to hitting, slapping, punching, biting and kicking.FRI 3000830

Based on interview, clinical record review and document review, the facility failed to ensure 1 of 19 sampled residents (Resident #62) was protected from potential misappropriation of property when an allegation a nurse stole the resident's medication was not reported to the Abuse Coordinator timely. This deficient practice placed all residents in the facility at risk for misappropriation of property due to delayed suspension of the alleged perpetrator and delayed investigation of the allegation.Findings include:Resident #62Resident #62 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure, unspecified whether with hypoxia or hypercapnia and other chronic pain.On 05/11/2026 at 11:54 AM, Resident #62 verbalized the resident had pain in both arms and took Lyrica to help manage the pain. The resident verbalized the resident would be in bad shape if the resident did not receive the medication and explained if one day's worth of medication was missed, the resident experienced a lot of pain. Resident #62 recalled there were two or three times the resident did not receive an ordered dose of Lyrica and was told the facility had run out of the medication. The resident verbalized the missed doses occurred when two specific staff members were working however, the two staff members no longer worked in the facility and the resident had not missed any more doses of pain medication.A final Facility Reported Incident (FRI) report submitted by the facility on 04/17/2026, documented two residents voiced concerns about pain management only when a specific nurse worked the unit. The date of the incident was 04/13/2026. The alleged perpetrator was a Registered Nurse (RN1) and the exact allegation against RN1 was RN1 may have been diverting medications.A Nurse's Note dated 03/06/2026, documented the nurse spoke to Resident #62's family member who informed the nurse Resident #62 mentioned problems regarding medications. The resident claimed medications were not being administered, nurses were not giving the resident Pregabalin (Lyrica) and may have been stealing the medication. Management would be made aware.A Nurse's Note dated 03/09/2026, documented by the Director of Nursing (DON), indicated the DON followed up with Resident #62 regarding the resident's Lyrica medication. The DON spoke with the Assistant DON (ADON) who was present on Friday and spoke with the primary nurse. The ADON stated Resident #62 was upset regarding the Lyrica being given. The ADON stated when removing the Lyrica from the packet, the medication broke in half. When the resident was shown this, the resident became upset. The DON spoke with Resident #62 on 03/09/2026 and the resident stated the resident did not know how a medication could break. The DON explained sometimes capsules break when pushing them out of the packet. The resident verbalized agreement but stated the resident was still suspicious.On 05/13/2026 at 3:14 PM, the DON verbalized misappropriation of resident property was when someone utilized a resident's property in a way not tolerated or wanted by the resident and included stealing money or using one resident's medication for another resident. The DON confirmed stealing a resident's medication would be considered misappropriation of resident property. If an allegation of abuse, neglect or misappropriation of property was reported to facility staff, the DON verbalized the expectation was the staff member would report the allegation immediately to the Administrator and/or DON. The Administrator was the facility's Abuse Coordinator (AC).The DON confirmed the DON was familiar with the allegations described in the FRI submitted 04/17/2026. The DON recalled a resident came to the DON and reported the resident felt like a certain nurse was not giving the resident their pain medication and the issue had been occurring for months. A few days later, Resident #62 reported to the DON the resident did not feel like the resident was getting their prescribed pain medication. The two residents were complaining about the same shifts the nurse of concern, RN1, worked in the facility. The DON recalled during the investigation into the allegations, the DON reviewed the Medication Administration Records (MARs) and narcotic logbook for the shifts RN1 worked. The DON denied any additional clinical record review was completed as part of the investigation.On 05/13/2026 at 3:42 PM, the DON reviewed the nurse's note dated 03/06/2026 indicating the resident's family member reported an allegation Pregabalin was not being administered to Resident #62 and nurses may have been stealing the medication. The DON confirmed the note documented an allegation of misappropriation of resident property and should have been reported immediately. The DON denied the allegation was reported to facility leadership.The DON confirmed the DON entered the nurse's note dated 03/09/2026 and explained the former ADON informed the DON Resident #26 had a concern about a Lyrica capsule being broken. The DON denied neither the nurse who documented the 03/06/2026 nurse's note nor the former ADON reported the allegation of misappropriation of property. The DON confirmed RN1 continued to work in the facility from 03/06/2026, when the allegation was made, until 03/27/2026.On 05/13/2026 at 3:59 PM, the Administrator confirmed the Administrator was the facility's AC and verbalized the Administrator/AC was usually responsible to conduct investigations when an allegation of abuse, neglect, or misappropriation of resident property was made. All allegations and/or suspicion of abuse, neglect, and misappropriation were to be reported to Administrator/AC immediately.The Administrator/AC confirmed the Administrator/AC was aware of the allegations documented in the FRI regarding Resident #62 and the resident's pain medications. The Administrator/AC recalled reporting the incident; however, explained the matter was mostly clinical and the DON conducted most of the investigation. The Administrator/AC reviewed the nurse's note dated 03/06/2026, confirmed the note documented an allegation of misappropriation of resident property and confirmed the allegation should have been reported immediately. The Administrator/AC denied the allegation was reported timely, denied an investigation was initiated immediately and denied any protections were put in place on or around 03/06/2026 to protect residents from misappropriation of property.The facility policy titled Pain Management, dated 04/11/2025, documented if a resident reported or there were signs of increased pain, the facility should evaluate whether there was a time or day pattern to ensure the problem was not due to drug diversion. The facility policy titled Abuse, Neglect and Exploitation, dated 04/11/2025, documented the facility would provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures to prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Possible indicators of abuse included but were not limited to: resident, staff or family report of abuse and resident reports of theft of property or missing property. An immediate investigation was warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occurred and the facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples of protection included responding immediately to protect the alleged victim and integrity of the investigation and room/staffing changes to protect the resident from the alleged perpetrator.FRI 2982885

Based on observation, interview, record review, and document review, the facility failed 1) to ensure a resident's chronic pain care plan included non-pharmacological interventions to manage the resident's pain for 1 of 19 sampled residents (Resident #2). This deficient practice had the potential to result in a resident's pain not being managed effectively. 2) to ensure a resident's dialysis care plan included interventions staff could implement to get the resident to agree to go to dialysis and education staff were to provide to the resident when the resident refused dialysis treatments for 1 of 19 sampled residents (Resident #97). This deficient practice had the potential to result in the resident experiencing life-threatening complications related to missing dialysis treatments without adequate knowledge of the possible outcomes of refusal. 3) to identify and document trauma-specific interventions for a resident with a known trauma diagnosis for 1 of 19 sampled residents (Resident #12). This deficient practice had the potential to result in re-traumatization due to the lack of individualized trauma-specific interventions in the care plan, and 4) to document respiratory care and interventions in the care plan for a resident with a diagnosis of respiratory failure who was receiving oxygen therapy for 1 of 19 sampled residents (Resident #71). This deficient practice had the potential to result in unrecognized changes in condition and inadequate monitoring for complications related to oxygen use due to the lack of respiratory-specific care plan interventions. 5) to ensure a resident's care plan included the physician ordered behavioral interventions, including psychotherapy, for a resident diagnosed with adjustment disorder with depressed mood for 1 of 19 sampled residents (Resident #88). This deficient practice had the potential to result in the resident not receiving the necessary behavioral health interventions to address their identified psychosocial needs. Findings include: Resident #2 Resident #2 admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified fracture of upper end of right humerus, sequela and unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing. On 05/11/2026 at 10:05 AM, Resident #2 verbalized the resident had pain in the resident's right leg. The resident verbalized the resident had a new pill but was unsure if it was working as the resident had continued pain causing the resident to spend more time in bed. The Medication Administration Record for Resident #2, dated May 2026, documented the resident's pain level on 05/12/2026 at 4:53 AM was six out of 10. The resident was administered a 2 milligram (mg) hydromorphone tablet for pain. The Pain Level Summary for Resident #2 documented the resident's pain was at a seven on 05/12/2026 at 8:02 AM. The resident's record lacked documented interventions implemented to address the resident's pain level. A chronic pain care plan for Resident #2 lacked non-pharmacological interventions to address the resident's pain. On 05/12/2026 at 12:17 PM, the Registered Nurse (RN) for Resident #2 confirmed the resident's pain level at 8:02 AM had been a seven and no interventions had been implemented to address the pain. The RN verbalized the RN was waiting to see if the hydromorphone the resident had received at 4:53 AM would help alleviate the resident's pain at 8:02 AM. On 05/12/2026 at 12:31 PM, the Director of Nursing (DON) verbalized the resident should have been evaluated to determine if a non-pharmacological intervention was needed when the resident's pain level was a seven at 8:02 AM and the resident's care plan should have included non-pharmacological interventions to address pain to ensure those interventions were provided. The facility policy titled Pain Management, dated 04/11/2025, documented interventions for pain management would be incorporated into the components of the comprehensive care plan. Non-pharmacological interventions would include environmental comfort measures, elevating or supporting limbs, physical modalities, exercises, and cognitive/behavioral interventions. The facility policy titled Comprehensive Care Plans, dated 04/11/2025, documented the care plan would include resident specific interventions reflecting the resident's needs and preferences. Cross reference with tag F697 Resident #97 Resident #97 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including end stage renal disease and dependence on renal dialysis. On 05/11/2026 at 8:54 AM, Resident #97 verbalized the resident usually went to dialysis on Mondays, Wednesdays, and Fridays; however, the resident had missed the last two scheduled dialysis treatments due to constipation and abdominal pain. On 05/11/2026 in the afternoon, a Registered Nurse (RN) verbalized Resident #97 refused to go to the resident's scheduled dialysis treatment in the morning. Progress notes in Resident #97's clinical record documented the resident refused to go to dialysis on 04/17/2026, 04/27/2026, 05/08/2026, and 05/11/2026. Resident #97's Care Plan documented the resident needed dialysis services and was at risk for complications related to refusals to go to dialysis. The Care Plan lacked interventions to address reasons for the refusal, education staff were to provide to the resident at the time of refusal, and any interventions used to get the resident to agree to go to dialysis. On 05/14/2026 at 8:45 AM, the DON verbalized potential complications of missing physician ordered dialysis treatments included physical decline of the resident, laboratory tests being outside normal limits, malaise, nausea, vomiting, and the resident feeling terrible. The DON explained the DON's expectation of staff if a resident refused to go to dialysis was the nurse would educate the resident about why it was important to go to treatment sessions, potential negative side effects of refusing the treatment, and how the body could not survive without it. If the nurse's education did not convince the resident to go to dialysis, the nurse was expected to get the physician involved and the physician was to educate the resident regarding potential outcomes. Education was to be provided each time the resident refused a scheduled dialysis treatment. The DON verbalized education was typically provided verbally. The nurse and the physician would later enter a progress note to document the education and what interventions were attempted to get the resident to agree to go to dialysis. If a resident had a history of refusals, the DON verbalized the DON would expect the resident's care plan to include tips and tricks on what worked to get the resident to agree to go to dialysis, education to provide to the resident at the time of refusal, and staff follow up with the resident. The DON confirmed the DON was familiar with Resident #97 and verbalized the resident was hit and miss with refusing dialysis treatments depending on how the resident was feeling. On 05/14/2026 at 1:10 PM, the DON confirmed Resident #97 refused to go to multiple dialysis treatments and denied the resident's care plan included tips and tricks which got the resident to agree to go and education to provide to the resident at the time of refusal. The facility policy titled Hemodialysis, reviewed 05/05/2026, documented the facility would assure each resident received care and services for the provision of hemodialysis consistent with professional standards of practice. The facility would communicate with the attending physician, dialysis facility and/or nephrologist for any canceled or postponed treatments and document any responses to the changes in treatment in the medical record. Dialysis could be stopped, postponed or delayed due to a resident's declination of the treatment or presence of an acute illness or complication to the resident before, during, after and in between dialysis sessions. The facility policy titled Comprehensive Care Plans, dated 04/11/2025, documented the care plan would include resident specific interventions reflecting the resident's needs and preferences. Resident #12 Resident #12 was admitted to the facility on [DATE], with a diagnosis of post-traumatic stress disorder (PTSD), unspecified. Resident #12's Health and Physical dated 04/10/2026, documented a diagnosis of PTSD. The facility Physician Diagnoses Verification Summary signed on 04/27/2026, documented Resident #12 had a diagnosis of PTSD. Resident #12's Minimum Data Set (MDS) 3.0 admission summary dated [DATE], Section I - Active Diagnoses, documented the resident had a diagnosis of PTSD. Resident #12's Care Plan lacked documentation of the resident's diagnosis of PTSD, the resident's history of trauma, the triggers and stressors to the resident, and any interventions to decrease the potential of re-traumatizing the resident. On 05/14/2026 at 11:31 AM, DON confirmed Resident #12's PTSD diagnosis and the resident's trauma indicators and interventions had not been documented in the resident's care plan. The DON verbalized the care plan should have included the resident's PTSD diagnosis and interventions so floor staff would know the resident's trauma indicators and the proper interventions. The facility policy titled, Trauma Informed Care, dated 06/15/2025, documented the facility would identify a resident's trauma-based triggers and interventions to decrease the re-traumatization of the resident, and those triggers and interventions would be documented in the resident's care plan. Resident #71 Resident #71 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease, unspecified. On 05/11/2026 at 8:46 AM, Resident #71 was sitting in a wheelchair in the resident's room. The wheelchair had an oxygen tank attached to the back of the wheelchair and the resident was wearing a nasal cannula connected to the tank. The oxygen tank's reading was at 2 liters per minute (LPM). The resident's room included an oxygen concentrator by the head of the resident's bed, and was not on. On 05/11/2026 at 8:47 AM, Resident #71 confirmed needing oxygen 24 hours a day and received oxygen either by the oxygen concentrator in the resident's room or the oxygen tank attached to the resident's wheelchair. A physician order dated 03/12/2026, documented oxygen 2 LPM via nasal cannula, continuous, every shift, related to chronic respiratory failure with hypoxia. Resident #71's MDS 3.0 quarterly assessment dated [DATE], Section O - Special Treatments, Procedures, and Programs, documented the resident was receiving oxygen therapy, and Section I - Active Diagnoses, documented the resident had a pulmonary diagnosis of respiratory failure. Resident #71's Care Plan lacked documentation of the resident's respiratory diagnoses, the administration of oxygen, the oxygen flow rates, and the monitoring of changes in condition and complications with the use of oxygen. On 05/14/2026 at 11:22 AM, the DON confirmed Resident #71's respiratory diagnosis and use of oxygen was not documented in the resident's care plan. The DON verbalized floor staff utilized the care plan to check for a residents care and interventions and confirmed Resident #71's respiratory diagnosis and oxygen use should have been documented in the resident's care plan. The DON verbalized having been responsible for completing audits to verify the accuracy and updates of resident care plans. The facility policy titled, Oxygen Administration, dated 04/11/2025, documented a resident's care plan shall identify the use and interventions for oxygen therapy, such as, the type of oxygen delivery system, when to administer or discontinue oxygen, the equipment setting for the prescribed flow rates, and the monitoring for complications associated with the use of oxygen. Resident # 88 Resident # 88 was admitted to the facility on [DATE] with diagnoses congestive heart failure, cardiomegaly, chronic kidney disease, stage four, generalized anxiety and psychoactive substance dependence. On 05/13/2026 at 8:02 AM, during an interview, Resident # 88 got teary and began speaking about the resident's grandson who was recently shot and killed in Reno, stating I'm experiencing a lot more anxiety and depression due to the recent situation. A physician's order dated 04/20/2026, documented for Behavioral Interventions for adjustment disorder with depressed mood, including psychotherapy, to talk and process the situational depression related to the recent violent death of Residents grandson and adjustment to long-term care placement. Encourage to participate in psychotherapy. Resident # 88 Care Plan lacked documented evidence to include psychotherapy. The Care Plan was initiated on 02/27/2026 and reviewed and updated on 03/10/2026 by the Assistant Director of Nursing (ADON). On 05/13/2026 at 10:23 AM the ADON confirmed that the updated interventions were not in the care plan and verbalized the staff would not have known how to care for the resident by only looking at the Care Plan. The ADON confirmed the Care Plan should have been updated. On 05/13/2026 at 3:38 PM, the Director of Social Work, verbalized the Care Plan was not updated and staff would not know how to care for the resident by only looking at the Care Plan dated 02/27/2026. A facility policy titled Comprehensive Care Plans, date implemented 04/11/2025, documented Comprehensive care plan included resident rights and meet the resident's medical, nursing and mental and psychosocial needs and to maintain the resident's highest practicable well-being. The Care Plan will be reviewed and revised after each comprehensive and quarterly MDS assessment, and alternative interventions will be documented, as needed. A facility policy titled Trauma Informed Care, date implemented 06/15/2025, documented, the facility will identify triggers and develop care plan interventions which minimize the effect of the trigger on residents.

Based on personnel record review, document review, and interview, the facility failed to ensure 2 of 20 sampled employees (Employee #4 and #17) had current cardiopulmonary resuscitation (CPR) training. This deficient practice placed residents at risk from an employee not having completed all employment eligibility requirements.Findings include:Employee #4Employee #4 was hired at the facility on [DATE], as an Assistant Director of Nursing.Employee #17Employee #17 was hired at the facility on [DATE], as a Registered Nurse.Employee #4 and #17 lacked documented evidence of a current CPR and first aid certification.On [DATE] at 2:46 PM, the Human Resources Coordinator (HRC) explained all licensed nurses were required to have a current CPR and first aid certification upon hire and expiration of the current certification. The HRC confirmed Employee #4 and #17 were licensed nurses and did not have a CPR and first aid certification.The facility policy titled Cardiopulmonary Resuscitation (CPR), implemented on [DATE], documented staff would maintain current CPR certification for healthcare providers through a CPR provider whose training included a hands-on session either in a physical or virtual instructor led setting in accordance with acceptable national standards.

Based on observation, interview, record review, and document review, the facility failed to ensure a resident's care related to a gastrointestinal (GI) infection was coordinated between the facility and the resident's established GI physician for 1 of 19 sampled residents (Resident #44) and interventions were implemented, including administration of physician ordered medications, to address a resident's constipation for 1 of 19 sampled residents (Resident #97). This deficient practice had the potential to result in a resident not receiving timely treatment and suffering from complications of a prolonged parasitic infection in the resident's GI tract or fecal impaction. Findings include: Resident #44 Resident #44 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including gastrointestinal hemorrhage, unspecified and enterocolitis due to clostridium difficile, not specified as recurrent. A GI specialist consultation note, dated 12/15/2025, documented the resident would continue to follow up with the specialist. A GI Panel laboratory result, dated 04/27/2026, documented the resident was negative for Clostridium difficile (C. diff) and positive for the parasite Entamoeba histolytica (a protozoan parasite infecting the GI tract with the ability to spread to other organs, most commonly the liver). The Care Plan for Resident #44, revised on 04/23/2026, documented the resident had a history of C.diff. The Care Plan lacked documentation of the resident's parasite infection. A Nursing Progress Note, dated 05/13/2026, documented the resident was receiving treatment for C.diff. The clinical record for Resident #44 lacked documentation the resident's established GI specialist was notified of the laboratory result from 04/27/2026 indicating the resident had an intestinal parasite infection. On 05/14/2026 at 1:10 PM, the Infection Preventionist (IP)/Assistant Director of Nursing (ADON) verbalized the resident's record should have included a charting alert documenting the resident had a parasitic infection, so staff were aware of the correct infection. The IP/ADON confirmed the IP/ADON was unable to provide documentation or evidence of the facility notifying the resident's GI specialist of the GI panel result documenting the resident had a parasite infecting the resident's GI tract. The IP/ADON verbalized the facility should have coordinated care with the resident's GI provider. Resident #97 Resident #97 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pleural effusion, not elsewhere classified and chronic respiratory failure with hypoxia. On 05/11/2026 at 8:54 AM, Resident #97 exhibited facial grimacing, belching, and was heard saying ow repeatedly prior to initiating the interview. The resident verbalized the resident had issues with constipation and had not had a bowel movement (BM) in a couple of days. The resident was nauseated and had pain in the resident's lower abdomen and rectum. The resident explained the lack of BM for multiple days, abdominal pain and nausea were previously reported to a nurse, and the resident took a medication for nausea; however, the medication was not effective. The Task: Bowel and Bladder Elimination record for May 2026 documented Resident #97 did not have a BM on the following dates: 05/01/2026, 05/03/2026-05/07/2026, 05/09/2026 and 05/10/2026. Resident #97's Care Plan documented the resident had a potential for constipation related to debility and End Stage Renal Disease (ESRD). Interventions initiated 02/07/2026 included: -Follow facility protocol for bowel management. -Monitor medications for side effects of constipation. Keep physician informed of any problems. -Monitor/document/report as needed for any signs/symptoms (s/sx) of complications related to constipation: agitation, abdominal distention, vomiting, small loose stools, fecal smearing, bowel sounds, abdominal tenderness, guarding, rigidity, and fecal impaction. Resident #97's Medication Administration Record (MAR) documented the following physician orders and administrations: -Fleet enema 7-19 grams/ 118 milliliters (ml) (sodium phosphates). Insert 118 ml rectally as needed (PRN) for constipation if no results from suppository, give next shift during waking hours only. Notify Medical Doctor (MD) if no results. The order date was 04/25/2026 and there were no administrations documented in the MAR. -Milk of Magnesia suspension 400 milligrams (mg)/ 5 ml (magnesium hydroxide). Give 30 ml by mouth every 24 hours PRN for constipation if resident does not have a BM for three days. Administer milk of magnesia per physician order on day four. The order date was 04/25/2026 and the discontinue date was 05/08/2026. There were no administrations documented in the MAR. -Ondansetron hydrochloride tablet 4 mg. Give one tablet by mouth every eight hours PRN for nausea and vomiting. The order date was 04/27/2026. The medication was administered on 05/07/2026, 05/09/2026, and 05/11/2026. Resident #97's clinical record lacked documented evidence staff implemented any interventions to address the resident's lack of BM from 05/03/2026-05/07/2026. On 05/14/2026 at 8:51 AM, the Director of Nursing (DON) verbalized when a resident had a BM, staff would document in the tasks section of the electronic medical record. Interventions the facility could implement to address constipation included asking the resident about the resident's normal frequency of BMs and administering PRN stool softeners, milk of magnesia, and lactulose. The physician's orders for PRN medications included instructions for when the medication was to be given based on how many days the resident had gone without a BM. The DON reviewed Resident #97's record, confirmed the record indicated Resident #97 did not have a BM from 05/03/2026-05/07/2026 (a five-day period), and confirmed the DON would have expected staff to have addressed the constipation. The DON verbalized the DON would have to verify if any interventions were implemented. On 05/14/2026 at 9:45 AM, the DON verbalized the DON had reviewed Resident #97's clinical record and confirmed there were no interventions implemented to address the resident's lack of BM for five days. On 05/14/2026 at 2:01 PM, the Administrator verbalized the facility did not have a policy related to bowel management or constipation and explained the facility would follow protocol/physician orders. The facility policy titled Medication Administration, last reviewed/revised 05/06/2026, documented medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice. The facility document titled Residents' Rights, undated, documented residents should receive the services and/or items included in the plan of care.

Based on observation, interview, record review, and document review, the facility failed to ensure a resident's report of pain was addressed with an intervention to reduce the pain level to the resident's acceptable level of pain for 1 of 19 sampled residents (Resident #2). This deficient practice had the potential to result in a resident experiencing prolonged pain at a level unacceptable to the resident causing the resident to experience diminished quality of life and emotional well-being.Findings include: Resident #2 Resident #2 admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified fracture of upper end of right humerus, sequela and unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing. On 05/11/2026 at 10:05 AM, Resident #2 verbalized the resident had pain in the resident's right leg. The resident verbalized the resident had a new pill but was unsure if it was working as the resident had continued pain causing the resident to spend more time in bed. A Pain Evaluation Assessment, dated 04/30/2026, documented the resident's acceptable pain level was four out of 10. The Medication Administration Record for Resident #2, dated May 2026, documented the resident's pain level on 05/12/2026 at 4:53 AM was six out of 10. The resident was administered a 2 milligram (mg) hydromorphone tablet for pain. The Pain Level Summary for Resident #2 documented the resident's pain was at a seven on 05/12/2026 at 8:02 AM. The resident's record lacked documented interventions implemented to address the resident's pain level. A chronic pain care plan for Resident #2 lacked non-pharmacological interventions to address the resident's pain. On 05/12/2026 at 12:17 PM, the Registered Nurse (RN) for Resident #2 confirmed the resident's pain level at 8:02 AM had been a seven and no interventions had been implemented to address the pain. The RN verbalized the RN was waiting to see if the hydromorphone the resident had received at 4:53 AM would help alleviate the resident's pain at 8:02 AM. The RN confirmed the RN had not implemented any interventions to address the resident's pain level of seven even though the resident's acceptable pain level was four. On 05/12/2026 at 12:31 PM, the Director of Nursing (DON) verbalized the resident should have been evaluated to determine if a non-pharmacological intervention was needed when the resident's pain level was a seven at 8:02 AM and the resident's care plan should have included non-pharmacological interventions to address pain to ensure those interventions were provided. The DON verbalized the DON would expect a pain medication to have been offered or for the RN to have paged the provider to ask for pain medication to alleviate the resident's pain. The DON verbalized if the resident had requested to not receive any interventions to alleviate the resident's pain, the RN would still be expected to reassess the resident's pain after an hour to determine if the resident's pain had improved or determine if the resident wanted an intervention to alleviate the resident's pain or if the resident continued to refuse. The facility policy titled Pain Management, dated 04/11/2025, documented interventions for pain management would be incorporated into the components of the comprehensive care plan. Non-pharmacological interventions would include environmental comfort measures, elevating or supporting limbs, physical modalities, exercises, and cognitive/behavioral interventions. If re-assessment findings indicated pain was not adequately controlled, the pain management regimen and plan of care would be revised as indicated. Cross reference with tag F656

Based on clinical record review, document review and interview, the facility failed to ensure residents with trauma diagnoses were assessed by the facility to recognize and respond to the effects of the trauma and implementation of interventions for 2 of 19 sampled residents (Resident #12 and #88). This deficient practice had the potential to result in a resident experiencing re-traumatization due to the lack of assessments to recognize trauma-specific interventions.Findings include: Resident #12 Resident #12 was admitted to the facility on [DATE], with a diagnosis of post-traumatic stress disorder (PTSD), unspecified. Resident #12's Health and Physical dated 04/10/2026, documented a diagnosis of PTSD. The facility Physician Diagnoses Verification Summary signed on 04/27/2026, documented Resident #12 had a diagnosis of PTSD. Resident #12's Minimum Data Set (MDS) 3.0 admission summary dated [DATE], Section I - Active Diagnoses, documented the resident had a diagnosis of PTSD. Resident #12's clinical record lacked documentation a trauma assessment, based on the resident's PTSD diagnosis, had been completed. On 05/14/2026 at 11:25 AM, the Director of Nursing (DON) confirmed a trauma assessment should have been completed for Resident #12 related to the resident's PTSD diagnosis, and the importance of assessing the resident's triggers to establish the appropriate interventions to help the resident cope, and decrease the potential of re-traumatizing the resident. Cross reference with Fag F656 Resident # 88 Resident # 88 was admitted to the facility on [DATE] with diagnoses congestive heart failure, cardiomegaly, chronic kidney disease, stage four, generalized anxiety and psychoactive substance dependence. On 04/20/2026 a psychiatric assessment confirmed Resident # 88's chronic illness (depression) was exacerbated due to the recent violent death of Residents grandson. On 04/20/2026 the physician ordered psychotherapy. On 05/13/2026 at 2:58 PM, the Administrator verbalized a trauma assessment would be completed upon admission by the Director of Nursing. On 05/13/2026 at 3:10 PM, the Assistant Director of Nursing, verbalized being aware of the assessments and confirmed trauma assessments were completed by the Social Worker. On 05/13/2026 at 3:58 PM, the Director of Social Services confirmed a trauma assessment had not been done upon admission for Resident #88, or after a traumatic event which occurred after admission. The Director of Social Services verbalized Resident # 88 did not have interventions in place in the Care Plan related to the traumatic life event. The facility policy titled Trauma Informed Care, implemented 06/15/2025, documented the facility is to provide care using approaches that address the needs of trauma survivors by minimizing triggers for re-traumatization. Cross reference F 656

Based on observation, interview, clinical record review, and document review, the facility failed to: 1) ensure a resident had the right to wear personal clothing, 2) provide a shower to a paraplegic resident who wished to take a shower, and 3) treat a resident with respect and dignity when a certified nursing assistant addressed the resident in a degrading manner, for 2 of 19 sampled residents (Resident #3 and #81). The deficient practice had to potential to cause psychosocial harm and mental anguish resulting from not being treated with dignity and respect.Findings include:Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including paraplegia, unspecified, adult failure to thrive, and atherosclerotic heart disease of native coronary artery without angina pectoris. Personal Items On 05/11/2026 at 12:29 PM, Resident #3 was lying in bed wearing a hospital gown and no personal items could be observed in the resident's room. The resident explained being admitted to the facility without any personal belongings. The resident had attempted on several occasions to have the facility assist the resident with obtaining the personal items left in the resident's apartment. The resident verbalized not feeling a need to talk with staff any longer because nothing would be done to accommodate the resident's request. The resident was wearing a hospital gown on 05/11/2026, 05/12/2026, 05/13/2026, and 05/14/2026. Resident #3's Personal Belongings Inventory sheet dated 04/06/2026, documented the resident was admitted with the following items: -black padded boots -one grey and blue hat -one grey wallet -one blue shirt. On 05/12/2026 at 2:18 PM, a Registered Nurse verbalized Resident #3 was dressed in a hospital gown everyday since admitting to the facility, as a result of not having any personal clothes. There was a surplus of clothes to provide to residents with no personal clothing and nothing has been offered to the resident. On 05/13/2026 at 10:25 AM, the Social Worker explained completing resident assessments and asking all residents if the residents were missing anything, if the resident needing anything, and went through a list of things with residents to see how the Social Worker can support the resident with the residents needs. In addition, the Social Worker would enter resident rooms on a daily basis to ask if all resident needs were being met. The Social Worker explained having not met Resident #3 to date and had not completed an assessment on the resident. On 05/14/2026 at 11:27 AM, Resident #3 was lying in bed in the resident's room, wearing a green hospital gown. Resident #3 explained having not met the Social Worker to date and was not holding the resident's breath waiting. On 05/14/2026 at 10:05 AM, the Director of Nursing (DON) confirmed Resident #3 only came in with four personal items and had not been accommodated, offered, or provided personal clothing in lieu of a hospital gown. The DON explained the resident should have been offered assistance with gathering the resident's personal clothing and offered clothing from the facility clothing surplus. The DON verbalized not having put eyes on the resident until 05/13/2026, and confirmed the resident was wearing a hospital gown. The DON explained the facility was supposed to be a homelike environment and clothes were to be provided and the resident assisted into clothing to feel at home. The facility policy titled Safe and Homelike Environment, last revised on 09/02/2025, documented the facility would create and maintain, to the extent possible, a homelike environment that de-emphasized the institutional setting. The facility would allow residents to use personal belongings, including clothing, to assist in creating and maintaining a homelike environment. The social service designee would encourage the resident to bring in personal belongings. Showers On 05/11/2026 at 12:29 PM, Resident #3 explained being admitted to the facility under the care of a hospice agency. The hospice agency would provide the resident with bed baths once every week or two; however, the resident wished to receive a shower. The resident verbalized aside from hospice, the facility had provided the resident one shower since admitting to the facility and offered no further showers. On 05/12/2026 at12:25 PM, Resident #3 was lying in bed in a green hospital gown. The resident reached into the hospital gown and pulled the resident's hand back out of the gown. On the resident's hands were pieces of skin. The resident explained the dying skin peeled from the resident's chest was from not receiving a shower and the resident's expressed the resident's head was also itching as a result. On 05/12/2026 at 2:18 PM, an RN verbalized the hospice agency was in charge of providing Resident #3 showers and the facility did not provide showers for that reason. The RN explained the facility had provided one shower to the resident and hospice provided only bed baths to the resident. On 05/12/2026 at 3:54 PM, the Hospice Licensed Practical Nurse (LPN) explained the resident was receiving bed baths once a week from hospice. The Hospice LPN was unaware of any other baths or showers offered to the resident. A Shower Schedule documented the resident received a bed bath on 05/07/2026 and 05/11/2026. On 05/14/2026 at 9:41 AM, a Certified Nursing Assistant (CNA1) verbalized all residents were to receive two showers per week; however, Resident #3 was only receiving bed baths from the hospice agency and the facility had not provided Resident #3 a shower. On 05/14/2026 at 9:53 AM, the DON explained the facility should be providing showers to Resident #3 and presented the resident's shower schedule. The shower schedule documented the resident had received a shower on May 7, May 11, and May 14, 2026. The DON was able to produce documented evidence within the shower schedules, hospice had provided bed baths for the resident and the facility had not provided showers to the resident. The DON confirmed the facility had not provided showers to the resident and verbalized if hospice was providing bed baths to the resident, the expectation would be for the staff to not be providing showers to the resident. A Follow-Up Question Report related to showering and bathing documented Resident #3 had only received three bed baths since admission to the facility and the bed baths were provided by the hospice agency. The Hospice Plan of Care dated 04/23/2026, lacked documented evidence hospice would provide bathing for the resident as a part of the terminal prognosis. The Hospice Plan of Care dated 05/05/2026, lacked documented evidence hospice would provide bathing for the resident as a part of the terminal prognosis. The facility policy titled Coordination of Hospice Services, implemented on 04/11/2025, documented when a resident was receiving hospice care and services, the facility would coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. The facility would coordinate care with the hospice provider and coordinate a plan of care and services that each entity would provide in order to meet the needs of the resident. The facility retained primary responsibility for implementing those aspects of care that were not related to the duties of the hospice agency. Residents receiving hospice would continue to receive the same facility services as residents who were not on hospice care. The facility policy titled Residents' Rights, undated, documented residents had the right to make their own choices and the facility must treat the resident with respect, dignity, and must care for the resident to promote quality of life. The resident must not be abused, neglected, or exploited by anyone. Cross reference tag F600 Resident #81 Resident #81 was admitted on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease unspecified, and non-st elevation (nstemi) myocardial infarction. On 05/11/2026 at 10:22 AM, CNA #2 entered Resident #81 room without knocking and stated, I was told it smelled like poop and to come change you. On 05/11/2026 at 10:32 AM, Resident #81 stated the comment about the poop was embarrassing and reported the CNA rarely knocked on the door before entering. On 05/11/2026 at 10:45 AM, the CNA #2 confirmed the statement may have embarrassed Resident #81 and should have knocked before entering the room. A facility policy titled, Residents' Rights, undated, documented facility must treat residents with dignity and respect and must care for residents in a manner that promotes residents' quality of life.

Based on observation, interview, clinical record review and document review, the facility failed to ensure 1) a medication was not left on a resident's bedside table and unattended by authorized staff for 1 of 3 residents observed during medication administration (Resident #4) and 2) expired medications were removed from 1 of 2 medication storage rooms and 1 of 2 medication carts inspected for medication storage. This deficient practice had the potential to result in residents and staff without authorization to have unsupervised access to medications and for expired medications to be administered to residents.Findings include:Medication left unattendedResident #4Resident #4 was admitted to the facility on [DATE], with a diagnosis of spinal stenosis, lumbar region with neurogenic claudication.An Order Summary Report for Resident #4 documented GlycoLax Powder (Polyethylene Glycol 3350), give 17 grams by mouth one time a day for constipation. The start date was 05/12/2026.On 05/13/2026 at 8:17 AM, a Registered Nurse (RN) began preparing medications for Resident #4 during the morning medication administration pass. The medications prepared by the RN included 17 grams of GlycoLax powder dissolved in six and a half ounces of water.On 05/13/2026 at 8:27 AM, the RN entered Resident #4's room and explained which medications had been prepared for the resident. After administering all other prepared medications, the RN handed the cup containing the GlycoLax powder dissolved in water to the resident and exited the room.On 05/13/2026 at 8:33 AM, the RN confirmed the RN left the GlycoLax in Resident #4's room. The RN verbalized the RN typically left medications such as laxative powders dissolved in liquids in residents' rooms as it was a lot of liquid for the residents to take in within just a few minutes and the RN had to continue with the medication pass.On 05/14/2026 at 1:17 PM, the Director of Nursing (DON) denied any medications were to be left in resident rooms. The DON explained it was important not to leave medications unattended by staff as staff would not know if the resident took the medication. Medication administration and refusals needed to be documented accurately and if medications were left at bedside, residents could store multiple doses and overdose.Expired medicationsOn 05/13/2026 at 1:26 PM, during an inspection of the Brookside unit medication storage room, a bottle of cherry flavored sore throat spray was found in an upper cabinet. An expiration date of 03/2026 was printed on the label. The Chief Nursing Officer (CNO) verbalized an expiration date written as month and year expired at the end of the month. The CNO confirmed the sore throat spray had expired.On 05/13/2026 at 1:41 PM, the DON verbalized if medications had expired the facility would dispose of the medication using drug buster (a solution to deactivate and destroy medications). The DON confirmed all expired medications were to be removed from medication carts and cabinets in the medication storage rooms in which active/current medications were stored. The medications were to be removed no later than the expiration date printed on the container.On 05/13/2026 at 1:44 PM, during an inspection of the Classics unit - 200 hall medication cart, a bottle of Vitamin D 25 microgram tablets was found. The expiration date printed on the bottle was 02/2026. A Licensed Practical Nurse confirmed the medication had expired and verbalized the medication should have been previously removed from the cart.The facility policy titled Medication Storage, reviewed/revised 05/06/2026, documented during a medication pass, medications were to be under the direct observation of the person administering medications or locked in the medication storage area/cart. Medication carts and rooms were routinely inspected by the consultant pharmacist or designee for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications would be destroyed in accordance with the facility's destruction of unused drugs policy.

Based on observation, interview, and document review, the facility failed to ensure a dietary recommendation was followed. This deficient practice had the potential to affect the resident's wellbeing and overall health.Findings include: On 05/13/2026 at 11:40 AM, during observation of the lunch tray line, a resident's diet ticket indicated a regular diet with no added salt. However, dietary staff placed two extra salt packets on the resident's tray. On 05/13/2026 at 11:45 AM, the dietary staff member confirmed the meal tray contained two salt packets. On 05/13/2026 at 12:00 PM, the Dietary Manager confirmed the resident's meal did not match the diet ticket and stated the ticket should have been followed to support resident health and comply with provider orders. A facility policy titled, Therapeutic Diet Orders, implemented 04/11/2025, documented the facility provided all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician.

Based on observation, interview, clinical record review and document review the facility failed 1) to prepare food as required for residents on a physician ordered therapeutic diet, 2) to ensure a resident received a minced and moist diet as ordered and failed to prepare or serve meals in a form that met the resident's need for 1 of 19 sampled residents (Resident # 3). This deficient practice had the potential for reduced meal intake due to not following the prescribed diet order, and increased the risk of difficulty swallowing, which could lead to choking and/or aspiration.Findings include:On 05/13/2026 at 11:40 AM, during an observation of lunch tray line, dietary staff served a whole chicken breast, green peas, and cornbread to three residents with a meal ticket indicating a minced and moist diet. The Dietician approved menu for 05/13/2026 documented minced and moist level five diet (MM5) was to include baked chicken, garlic mashed potatoes, sliced carrots, soaked cornbread, margarine, vanilla pudding, and coffee and milk. On 05/13/2026 at 11:50 AM, the Dietary [NAME] verbalized being unaware of what the MM5 diet was. On 05/13/2026 at 12:00 PM, the Dietary Manager confirmed residents' meals did not match their diet tickets and stated the tickets should have been followed to prevent a choking hazard. A facility policy titled, Therapeutic Diet Orders, implemented 04/11/2025, documented therapeutic diets, including mechanically altered diets where appropriate, would be based on the resident's individual needs as determined by the resident's assessment. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including paraplegia, unspecified, adult failure to thrive, and atherosclerotic heart disease of native coronary artery without angina pectoris. On 05/11/2026 at 12:29 PM, Resident #3 was in bed, in the resident's room, with a meal tray on a table next to the resident. The food on the tray was untouched. Resident #3 verbalized the food was horrible and hard to chew. Resident #3's diet order dated 04/23/2026, documented a regular diet, Level 5 Minced & Moist (MM5) texture, Regular/Level 0 Thin consistency for difficulty chewing. The Nutritionally At-Risk Resident Interdisciplinary Team Review dated 05/07/2026, documented the resident was to be provided and served the diet as ordered with intake monitoring at each meal. On 05/12/2026 at 12:21 PM, Resident #3's meal tray was delivered to the resident's room. The tray had a whole ham steak with gravy on the top, Brussel sprouts, sweet potato mash, a dinner roll, and a bowl of baked apples. The meal ticket documented a regular diet, thin liquids, and no hard to chew foods. On 05/12/2026 at 12:25 PM, Resident #3 explained the resident had dentures and the dentures fit well; however, food collected underneath the dentures, and it was painful to eat. The resident preferred to eat without the dentures; however, the food was hard to chew. The resident verbalized a willingness to eat the brussels sprouts and the ham steak if the resident would be able to chew the food. On 05/12/2026 at 1:21 PM, the resident's lunch tray demonstrated the resident had consumed approximately 1/4 cup of brussels sprouts, one bite of ham steak, and the sweet potato mash. Resident #3 verbalized the brussels sprouts were burnt and the ham was too hard to chew. On 05/12/2026 at 2:18 PM, a Registered Nurse (RN) explained all staff were instructed to document meal consumption for Resident #3, after each meal provided. The RN reviewed the meal consumption log and verbalized staff had documented 26-50% intake for lunch the previous day. The RN confirmed Resident #3 had a current and active diet order for minced and moist foods. On 05/13/2026 at 11:40 AM, during trayline, the [NAME] was taking temperatures of the food prior to plating and serving to residents for lunch service. The [NAME] obtained temperatures of three foods to be served for residents on a minced and moist diet. The [NAME] verbalized residents on a minced and moist diet were to be served chicken and carrots cut up into very small pieces, and mashed potatoes. On 05/13/2026, the Kitchen Manager explained all residents receiving a minced and moist diet would be served the food cut up into small pieces and verbalized residents on minced and moist diets should not ever receive a whole piece of chicken. The Kitchen Manager verbalized dietary aids would call out the diet orders, the [NAME] would plate the diet order onto the resident plate, and lastly, the dietary aide would flip the ticket on the resident's plate so the [NAME] was able to verify correct plating. On 05/13/2026 at 12:11 PM, the [NAME] plated Resident #3's plate. The plate contained a full chicken breast and pieces of sliced carrot. The dietary ticket for the lunch meal documented regular diet, thin liquids, and no hard to chew foods. On 05/13/2026 at 12:21 PM, the Kitchen Manager verbalized Resident #3 was on a regular diet; however, would go to the Kitchen Manager's office to verify validity of the resident's diet. The Kitchen Manager returned and confirmed Resident #3 was on a minced and moist diet and the food being served to the resident did not follow the resident's prescribed diet order. The Kitchen Manager explained not serving the prescribed diet could result in weight loss for the resident and other hazards due to swallowing difficulties. The facility policy titled Therapeutic Diet Orders, implemented on 04/11/2025, documented therapeutic diets, including mechanically altered diets would be provided to residents as prescribed. Therapeutic diets would be considered for inadequate nutrition, nutritional deficits, weight loss, medical conditions, and difficulty swallowing. The dietary staff and nursing staff were responsible for providing resident diets in the appropriate form to a resident.

Based on observation, interview, and document review, the facility failed to ensure the outside garbage receptacles were sealed (lid closed) and free of debris on the surrounding pavement. This deficient practice had the potential to affect all residents in the facility by increasing the risk of pest and foodborne illnesses.Findings include: On 05/11/2026 at 9:22 AM, two dumpsters were located at the back of the facility. One dumpster had an open lid with exposed trash, and the second dumpster had trash on the ground around it, including gloves, cans, and paper. On 05/11/2026 at 9:30 AM, the Dietary Supervisor explained it was important to keep the dumpster area clean and the lids closed to prevent animals and pests. A facility policy titled, Disposal of Garbage and Refuse, implemented 04/08/2026, documented refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be covered when not being loaded. Surrounding areas shall be kept clean to minimize the accumulation of debris and insect/rodent attractions.

Based on document review and interview, the facility failed to update the facility assessment following a change in the medical provider group. This deficient practice had the potential to result in the facility assessment not accurately reflecting the current medical provider or clinical responsibilities of the newly contracted medical provider group providing necessary services to residents. Findings include: The facility's assessment updated 03/19/2026, documented a third-party vendor as the primary medical practitioners providing care to residents. The assessment documented the facility would review and update the facility assessment whenever changes required modifications to any part of the assessment. On 05/13/2026 at 12:33 PM, the Administrator confirmed the facility had recently changed the contracted medical group and provider as of 03/11/2026, and the third-party vendor was no longer the contracted medical provider group for the facility. The Administrator verbalized having been responsible for updating the facility assessment but had missed updating the change of provider group in the language of the assessment. The facility assessment updated 03/19/2026, lacked documented language the assessment had been updated following a change in its medical provider structure, including the transition of the facility's primary attending physician and associated on call coverage. The facility assessment referenced the previous medical group and did not reflect the qualifications, availability, scope of services, or clinical responsibilities of the newly contracted medical provider group necessary to meet resident needs. The facility policy titled, Facility Assessment revised 03/10/2026, documented the facility assessment would be reviewed and updated as necessary, or at least annually, or whenever the facility plans for or has a change that required a modification or update to the assessment.

Based on interview and document review, the facility failed to designate a member of the facility's interdisciplinary team responsible for coordinating the care of residents receiving hospice services. This deficient practice had the potential to result in uncoordinated care and a lack of communication between the facility and the hospice providers, delays of resident care, inadequate monitoring, and an increased risk of unmet physical, emotional, and psychosocial needs for residents receiving hospice services.Findings include: On 05/12/2026 at 12:57 PM, the Assistant Director of Nursing (ADON) verbalized the ADON was not the facility's hospice coordinator and was unaware who was responsible as the facility's hospice coordinator. On 05/12/2026 at 2:00 PM, the Administrator confirmed having been aware of the requirement for the facility to have a hospice coordinator, but the facility did not currently have a hospice coordinator. The Administrator verbalized hospice services were coordinated as a team effort with several facility staff but the oversite of hospice care to residents should have been the Director of Nursing. On 05/12/2026 at 2:06 PM, the DON verbalized the DON was not the hospice coordinator, and it was the responsibility of the respective ADONs to manage the residents on hospice care within their units. On 05/12/2026 at 4:26 PM, the Administrator verbalized the facility did not have a policy on the requirement of a hospice coordinator, only the Coordination of Hospice Services policy. On 05/14/2026 at 11:33 AM, the DON confirmed the facility did not currently have a hospice coordinator and as a result had the potential of a resident on hospice not receiving the proper coordinated care.The facility policy titled, Coordination of Hospice Services, dated 04/11/2025, lacked documented language of the requirement of the facility designating a member of the interdisciplinary team to have been responsible for coordinating the care of residents receiving hospice services.

Based on observation, interview, clinical record review, and document review, the facility failed to provide reasonable accommodation by not ensuring a resident's electric wheelchair was repaired and made available for use for 1 of 19 sampled residents (Resident #8). This deficient practice had the potential to cause the resident emotional distress. Findings include:Resident #8Resident #8 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, in partial remission, anxiety disorder, unspecified, and other sequalae of cerebral infarction.On 05/11/2026 at 2:15 PM, Resident #8 verbalized the resident had an electric wheelchair and had not been able to use the wheelchair since admitting to the facility. The resident had no idea where the wheelchair had gone and verbalized the resident had not gotten out of bed and gone out into the facility's common areas. The resident explained the resident's right leg was non-operational and could not be moved and because the resident had remained in bed, both the left and right heels had begun to hurt.Resident #8's Personal Belonging Inventory, dated 11/12/2025, documented the resident was admitted to the facility with one electric chair with a charger.On 05/12/2026 at 2:07 PM, the Activities Director verbalized Resident #8 rarely came out of the resident's room due to difficulty sitting and was unaware the resident had an electric wheelchair.On 05/12/2026 at 2:20 PM, a Registered Nurse (RN) verbalized Resident #8 used to have an electric wheelchair and had arrived at the facility with a personal electric wheelchair. The RN explained being under the impression the electric wheelchair did not have a footrest; however, the electric wheelchair was operational. Maintenance would not touch the resident's wheelchair because the wheelchair was a safety liability for the Maintenance Director.On 05/12/2026 at 2:52 PM, the Maintenance Supervisor confirmed Resident #8 had an electric wheelchair; however, the wheelchair had been sitting in the dining room for about two weeks. The Maintenance Supervisor verbalized the electric wheelchair was missing a footrest but was not able to repair the footrest due to not being certified to work on the wheelchair. The Maintenance Supervisor verbalized the manufacturing company should have been contacted to fix the resident's wheelchair but had not been notified.On 05/12/2026 at 2:55 PM, an electric wheelchair was observed in the corner of the dining room.On 05/14/2026 at 9:47 AM, the Director of Nursing (DON) verbalized Resident #8 was admitted to the facility in October 2025 with an electric wheelchair, which was documented on the inventory sheet. The DON confirmed the wheelchair was sitting in the dining room and the DON did not know how long it had been there. The DON admitted the DON learned during the survey week that the wheelchair belonged to Resident #8. The DON explained the DON did not know what was wrong with the wheelchair and had heard that Resident #8 wanted a seatbelt attached. The DON verbalized that maintenance would be expected to address the issue, or physical therapy would order the needed accessory. The DON did not know why the issue had not been addressed and confirmed Resident #8 had not been accommodated, as the facility had not repaired the electric wheelchair.On 05/14/2026 at 11:42 AM, the DON explained the family of Resident #8 had been contacted and the family had ordered a new seatbelt and footrest for the electric wheelchair. The DON verbalized the DON would provide the email correspondence with the family.On 05/14/2026 at approximately 3:00 PM, the DON verbalized the DON was unable to locate an email chain with the resident's family confirming discussion of, and the ordering of, parts for the electric wheelchair. The DON confirmed the resident had been without the resident's wheelchair for quite some time with no accommodation provided by the facility to repair the electric wheelchair.The facility policy titled Promoting/Maintaining Resident Self-Determination, last revised 05/06/2026, documented the facility was in the practice of promoting and protecting resident rights by facilitating resident self-determination through support and resident choice. The facility would ensure each resident had the opportunity to exercise autonomy related to the things that were important to the resident's life such as interests and preferences.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a potential incidence of misappropriation of a resident's prescribed narcotic pain medication was investigated for misappropriation of property for 1 of 2 residents reviewed for potential narcotic diversion (Resident #44). This deficient practice could lead to undetected narcotic diversion from residents causing increased pain and diminished quality of life. Additionally, the facility failed to thoroughly investigate a resident's allegation of abuse and ensure a suspended employee did not continue to work in the facility until an investigation was completed for 1 of 19 sampled residents (Resident #19). Resident #19 alleged a male staff member touched the resident inappropriately while checking the resident's brief. One of the male staff members working at the time the allegation occurred was scheduled and continued to work in the facility from the time the facility was made aware of the allegation on 05/16/2024, until 05/23/2024. The lack of a thorough investigation and failure to prevent the staff member from working in the facility allowed an alleged perpetrator continued access, with the potential for further abuse, to the alleged victim and all other residents in the facility. On 05/23/2024 at 3:05 PM, the Administrator was notified of Immediate Jeopardy (IJ) related to the failure to thoroughly investigate an allegation of abuse and failure to protect Resident #19 and all other residents in the facility from an alleged perpetrator during the facility's investigation. The IJ began on 05/16/2024, when the facility was made aware of the allegations of abuse by Resident #19 of being touched inappropriately by a male staff member. The lack of a thorough investigation into the allegation and protection of residents by failing to ensure a suspended employee did not continue to work in the facility had the potential to result in sexual abuse and cause harm to all residents in the facility. On 05/23/2024 at 4:23 PM, the plan to remove the immediacy for F610 was accepted by the State Agency (SA) and included the following summarized actions: -The alleged perpetrator was suspended to ensure completion of the investigation regarding care provided to the resident of concern on the date of the incident. -All residents were interviewed related to sexual abuse, and non-interviewable residents were assessed for sexual trauma. -All facility staff would be educated on Abuse Prevention and Investigation. On 05/29/2024, while onsite and after confirming the facility's implementation of the immediate corrective action completed on 05/24/2024 at 5:00 PM, the IJ was removed in the presence of the Administrator. The deficient practice remained at a scope of D and the severity lowered to potential for minimal harm following the removal of the IJ. The facility's implementation of the plan to remove the immediacy of the IJ was verified as follows: Interviews were conducted with two Registered Nurses (RN), one Licensed Practical Nurse (LPN), three Certified Nursing Assistants (CNA), seven residents, the Director of Nursing Services (DNS), the Administrator, the Divisional Director of Clinical Operations (DDCO), and the Staff Development RN. Review of the Empress Caring Representative (ECR) Checklists completed with all residents on 05/23/2024, documented all residents were interviewed and screened for the following: -Ability to make choices about daily life which were important to the resident. -Did staff treat the resident with dignity and respect. -Did residents get the help and care needed without waiting a long time. -Confrontations with staff and/or other residents -Sexual abuse -Observation or personal experience of the following: being treated with humiliation, mean things said, hurt (treated roughly, slapped, hit, shoved), or a situation which made the resident feel uncomfortable. Review of the Inservice Education Summary, dated 05/23/2024, documented the Divisional Director of Clinical Operations (DDCO), the Administrator, the Director of Nursing Services (DNS), and the Resident Care Manager (RCM) received education via lecture and handouts on the following topics: -Abuse investigation policy -Abuse investigation pathway -Investigation of alleged sexual abuse -Abuse policy Review of training certificates documented all staff received training related to abuse identification and reporting and the facility's policy titled Abuse Investigation. The training was completed as of 05/24/2024. Findings include: Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including spondylosis without myelopathy or radiculopathy, lumbar region, anxiety disorder, unspecified and depression, unspecified. An initial Facility Reported Incident (FRI) dated 05/16/2024, documented Resident #19 alleged the resident was sexually abused by a male staff member. The resident alleged the male staff member inserted the staff member's finger into the resident's rectum and vagina. On 05/20/2024 at 10:54 AM, Resident #19 recalled a male staff member touched Resident #19 inappropriately. The incident was reported to staff. On 05/20/2024 at approximately 12:20 PM, a female staff member entered Resident #19's room. The female staff member verbalized the female staff member was looking for a Certified Nursing Assistant (CNA). The female staff member described the CNA as a tall man. Upon mention of a tall man, Resident #19 appeared frightened, pulled a blanket over the resident's body, and began to cry. A progress note dated 05/16/2024, documented Resident #19 reported the incident to a Licensed Practical Nurse (LPN). A skin assessment was completed and the Advanced Practice Registered Nurse (APRN) was notified. An Investigator's Interview Statement of Event dated 05/17/2024, documented Resident #19 reported to an LPN a male employee put the employee's fingers inside the resident's vagina and anus every time the employee had to change the resident's brief. The date of event was documented as 05/16/2024. A timeline of events provided by the facility, related to the incident on 05/16/2024, documented the following: -On 05/16/2024, a facility investigation was initiated. Possible alleged persons, a CNA and a Nurse-Aid in Training (NAT), were suspended pending an investigation. -On 05/17/2024 at 10:00 AM and 3:45 PM, phone calls were placed to the NAT to obtain an interview statement. -On 05/18/2024 at 2:00 PM, the facility had not received a return phone call from the NAT. An additional phone call was placed to the NAT and the facility was awaiting a return call. -On 05/20/2024 at 12:36 PM, a phone call was placed to the NAT to reiterate the removal of the NAT from the schedule until an interview statement could be obtained, the facility was awaiting a return call. A Disciplinary Action Form documented the DNS interviewed the NAT on 05/20/2024. The allegations were not substantiated, and the NAT returned to work on 05/20/2024. An Investigator's Interview Statement of Event dated 05/20/2024, documented the NAT was interviewed regarding the alleged incident on 05/16/2024. The interview was conducted by the DNS and the Administrator. The NAT confirmed the NAT worked the night (NOC) shift on 05/15/2024. The NAT denied going to the side of the building where Resident #19 resided. The NAT denied having worked with Resident #19 or entering Resident #19's room during the shift. On 05/20/2024 at 8:47 AM, a CNA explained the CNA knew what tasks or care were required for each resident by checking the electronic medical record. Tasks were documented as soon as care was provided. Resident #19's clinical record indicated the NAT completed the following tasks for Resident #19 on 05/15/2024 at 9:56 PM: bladder monitor, bowel monitor, hour of sleep snack, meal monitor, fluids, and turn and reposition frequently with shift care rounds as tolerated/as allowed by resident. On 05/23/2024 at 12:15 PM, the DNS confirmed the DNS was aware of the allegation of sexual abuse reported by Resident #19. The DNS recalled actions taken to protect Resident #19 during the facility's investigation included removing any male caregivers from the resident's care and a social worker met with the resident. The DNS verbalized interviews were conducted with the male staff who were potential suspects, a CNA and an NAT. The CNA and NAT denied going into Resident #19's room during the shift when the alleged sexual abuse occurred. The DNS verbalized the investigation was complete and the CNA and the NAT were cleared to return to work on 05/20/2024. The DNS denied the DNS completed a review of Resident #19's clinical record as part of the investigation into the allegation of sexual abuse. The DNS verbalized the DNS could have reviewed the clinical record to verify if either the CNA or the NAT provided care to Resident #19. During the interview, the DNS reviewed Resident #19's clinical record and confirmed the clinical record indicated the NAT provided care to Resident #19 during the NOC shift on 05/15/2024. The DNS denied it would be common for staff to document in a resident's clinical record if the staff member was not providing care to the resident. The DNS confirmed investigation into an allegation of abuse would typically include a review of the resident's clinical record. On 05/23/2024 at 12:44 PM, a copy of the NAT's timecard was provided by Human Resources (HR) Staff. The NAT's timecard documented the following: -The NAT worked from 5:59 PM on 05/15/2024, until 6:02 AM on 05/16/2024. -The NAT worked from 5:45 PM on 05/16/2024, until 6:01 AM on 05/17/2024. -The NAT worked from 6:11 PM on 05/17/2024, until 6:02 AM on 05/18/2024. -The NAT worked from 5:55 PM on 05/18/2024, until 6:02 AM on 05/19/2024. -The NAT worked from 5:53 PM on 05/20/2024, until 5:56 AM on 05/21/2024. -The NAT worked from 5:51 PM on 05/22/2024, until 6:03 AM on 05/23/2024. On 05/23/2024 at 1:01 PM, during an interview with the DNS and the Divisional Director of Clinical Operations (DDCO), the DNS explained when an allegation of abuse was made, the DNS would suspend the alleged perpetrator(s) until the investigation had been completed. If the investigation found the employee(s) was not responsible or involved, the employee(s) would be allowed to return to work. The DNS explained it would have been appropriate to suspend any male employee working at the time the alleged sexual abuse of Resident #19 occurred. The DNS verbalized the CNA was initially suspended when the facility began the investigation. During the investigation, the DNS learned the NAT was also working the NOC shift on 05/15/2024. The DNS verbalized the DNS made several calls to the NAT to inform the NAT of the suspension until the completion of the investigation however, the DNS was not able to contact the NAT until 05/20/2024. The DNS verbalized the NAT did not work between 05/16/2024 and 05/20/2024. On 05/23/2024 at 1:07 PM, the DNS and the DDCO reviewed the NAT's timecard and confirmed the timecard documented the NAT worked the NOC shifts beginning on 05/15/2024, 05/16/2024, 05/17/2024, 05/18/2024, 05/20/2024 and 05/22/2024. When asked, if due to the DNS's failure to reach the NAT by phone, anyone remained in the facility to notify the NAT the NAT was suspended and could not work until the completion of the investigation, the DNS verbalized the DNS could not confirm anyone stayed to notify the NAT. The DNS reviewed the facility's schedule for 05/23/2024, and confirmed the NAT was scheduled to work the NOC shift. The DNS verbalized there was a potential for further abuse to all residents when a suspended employee was allowed to continue to work unsupervised in the facility while an investigation was ongoing. The facility policy titled Notice of Resident Rights Under Federal Law, updated 11/2016, documented residents had the right to be free from verbal, sexual, physical, or mental abuse. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated 10/2022, documented each resident had the right to be free from abuse including verbal, mental, sexual or physical abuse. The facility implemented policies and processes so residents were not subjected to abuse by staff. The policies addressed screening, training, prevention, identification, investigation, protection, and reporting/response. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse was defined as non-consensual sexual contact of any type. The facility was to conduct a thorough investigation of allegations of abuse in accordance with state and federal regulations and referred to the abuse investigation policy. The facility was to protect residents from harm during and after the investigation and referred to the abuse protection policy. The facility policy titled Abuse Protection, updated 10/2022, documented the facility was to protect residents from physical and psychosocial harm during and after an investigation. The facility was to suspends and/or removes the alleged perpetrator from patient care areas immediately. The facility policy titled Abuse Investigation, updated 10/2022, documented the facility was to conduct a thorough investigation of allegations of abuse. The facility was to protect the alleged victim during and after the course of the investigation according to the abuse protection policy. Cross reference with F835 FRI #NV00071208 41848 Resident #44 Resident #44 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, and aphasia. On 05/22/2024 at 2:25 PM, a Registered Nurse (RN) from a contracted hospice agency verbalized the hospice had to replace a bottle of liquid Morphine for Resident #44 on 05/21/2024. The RN explained the bottle appeared to have been tampered with, the medication was discolored, and there was a paper like substance visible in the bottle. An Order Summary Report for Resident #44, documented Morphine Sulfate (concentrate) solution 20 milligrams (mg)/milliliter (ml), give 5 mg by mouth every four hours as needed for pain. The order start date was 01/31/2024. The narcotic count sheet for Resident #44's Morphine Sulfate documented a bottle containing 13.25 ml was discarded on 05/21/2024, due to discoloration. On 05/22/2024 at 3:23 PM, the Resident Care Manager (RCM) verbalized the RCM was not aware of any concerns regarding Morphine needing to be discarded for Resident #44. On 05/22/2024 at 3:30 PM, the Director of Nursing Services (DNS) verbalized the DNS was not aware of any issues with a resident's Morphine being discarded due to discoloration. The DNS verbalized if the DNS was made aware of any such issue, the DNS would immediately start an investigation, including interviewing all involved and reviewing narcotic counts. On 05/22/2024 at 3:37 PM, the RN for Resident #44 verbalized the RN had discarded the Morphine with the hospice RN on 05/21/2024. The RN explained the hospice RN wanted to discard because the Morphine appeared watered down, there was a substance floating in the liquid, and the self-sealing bottle adapter had been removed. The RN verbalized the RN, and the hospice RN notified the DNS the medication needed to be discarded. On 05/22/2024 at 4:02 PM, the DNS confirmed the incident had not been reported or investigated as potential misappropriation of resident property. The DNS verbalized the facility would begin investigating the concern. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated 10/2022, documented the facility would conduct a thorough investigation of potential, suspected, and/or allegations of misappropriation of resident property in accordance with state and federal regulations. Cross reference with tag F609

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a head-to-toe assessment was completed by a licensed qualified professional when a resident with an injury to the left side of the head and at high risk for intracranial hemorrhage was found on the floor after a fall and was reported timely to a physician for 1 of 19 sampled residents (Resident #16), and a wound was identified and reported to the appropriate staff, treated, and documented for 1 of 19 sampled residents (Resident #4). Finding include: Resident #16 Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including muscle weakness, dementia, and lack of coordination. A Nursing Progress Note dated 06/26/23 at 9:45 AM signed by a Licensed Practical Nurse (LPN), documented Resident #16 was witnessed falling from the resident's wheelchair, in the resident's room, in front of the bed. Resident #16 hit the left side of head on dresser. Resident #16 explained the resident was attempting to sit in the wheelchair and the chair came out from underneath while attempting to sit causing the fall. Resident #16 was assessed for injury and assisted to wheelchair with assistance of three staff. Noted increased swelling to left side temple/eye. Administered Tylenol for pain, ice pack applied, the Advanced Practice Registered Nurse (APRN) provided order. APRN and family notified of event. APRN provided order to send to the emergency room (ER) for eval and treatment related to head injury and history of seizures. A Physician Progress Note dated 06/26/23 at 4:03 PM signed by a APRN, documented Resident #16 was seen today after experiencing a ground-level fall. It was unclear if the fall was witnessed or unwitnessed. Resident #16 had a significant injury to the left eye with periorbital edema and pain. There was no significant laceration or need for suturing. Patient was somewhat confused at baseline however, the resident has been more altered recently than baseline. Immediately post fall there were no neurological deficits and vital signs were stable however, given the resident was on aspirin therapy and high risk for intracranial hemorrhage, will need to be evaluated with a Computed Tomography (CT) scan in the emergency department to rule out bleeding. A Nursing Progress Note dated 06/29/23 signed by an LPN, documented the fall from 06/26/23, was unwitnessed. Resident #16's clinical record lacked documented evidence of a head-to-toe assessment completed by a licensed qualified professional after the unwitnessed fall on 06/26/23, until Resident #16 was seen by the APRN. On 06/29/23 at 2:37 PM, during a telephone interview, the APRN verbalized receiving three calls from the facility on 06/26/23 at 10:37 AM, 10:39 AM, and 10:46 AM. The APRN spoke with a Licensed Practical Nurse and ordered an ice pack for Resident #16. The APRN recalled not arriving at the facility until after 11:00 AM. Upon arrival to the facility, an assessment was conducted on Resident #16, and due to the aspirin therapy, the APRN sent the resident out for a CT scan for potential intercranial hemorrhage. On 06/29/23 at 3:10 PM, the Assistant Director of Nursing (ADON)/Licensed Practical Nurse (LPN) explained having conducted a post fall head to toe assessment on Resident #16. The ADON/LPN verbalized the completion of the assessment to be within the job scope. On 06/29/23 at 3:34 PM, a LPN explained Resident #16 was confused, and attempted to self-transfer to the toilet. The LPN verbalized when a resident had an unwitnessed fall a head-to-toe assessment for body movements was conducted to ensure nothing was broken or the resident was not in pain. After the assessment would conduct vitals, check on resident through the day doing a body assessment. On 06/29/23 at 3:50 PM, the Director of Nursing (DON) explained when a resident had an unwitnessed fall, staff was to start neuro checks and assess the fall to make sure the resident was ok and then call the provider, if new orders were received from the provider, follow out the new orders. Determine root cause, complete the risk management, and update the care plan. The head-to-toe assessment included identifying any injuries, pain, scrapes, and if it was safe to move the resident, which was everything required to complete as a nurse. The DON verbalized an LPN can conduct the head-to-toe evaluation after a fall. The DON explained the ADON/LPN completed a head to toe assessment after Resident #16 fell on [DATE] at 9:45 AM and the APRN conducted a head-to-toe assessment upon arrival in the facility. On 06/29/23 at 5:36 PM, the Administrator verbalized the facility followed the State of Nevada Nursing Practice Standards. The Nevada Nursing Practice Standards documented a LPN may not independently carry out those duties which require the substantial judgment, knowledge and skill of a registered nurse. An LPN shall contribute to the plan of care established for a patient by recording and reporting to the appropriate person his or her observations by conducting a focused nursing assessment. Cross referenced with tags F726. 30748 Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including fusion of spine, lumbar region, difficulty in walking and paresthesia of skin. On 06/26/23 at 12:13 PM, Resident #4 was bleeding from what appeared to be a puncture mark with a deep scratch from the right forearm. The blood was dripping from the resident's arm onto the clothing the resident was wearing. Resident #4 explained the wound had been there for about a month and the resident did not know how the wound started. Resident #4 verbalized staff were aware of the wound, however, had never tended to the wound, cleaned the wound and the wound had gotten much worse. Weekly Skin Observations lacked documented evidence Resident #4 had a wound on the following dates: -May 1, 2023 -May 9, 2023 -May 15, 2023 -May 22, 2023 -May 30, 2023 -June 5, 2023 -June 12, 2023 -June 19, 2023 -June 26, 2023 Resident #4's clinical record lacked progress notes identifying a wound and lacked a care plan for the interventions and goals used to treat the wound. On 06/28/23 at 7:39 AM, Resident #4 had a large band-aid covering the wound on the right forearm. Resident #4 verbalized a staff member had put a band-aid on the wound the previous night, however, staff did not clean nor put any medication on the wound. Resident #4 expressed the wound was bothersome. On 06/28/23 at 8:54 AM, the DON verbalized a wound could be a scratch, a bump or any skin irregularity. Once a wound was identified by a nurse, the wound, to include interventions would be transcribed onto the care plan, assessments would be completed, and physician orders would be obtained to provide wound care. On 06/28/23 at 2:46 PM, a Registered Nurse (RN) explained Resident #4 had weekly skin assessments completed by a licensed nurse. The skin assessments would identify any type of wound or pressure ulcer the resident may have. The RN verbalized Resident #4 last had a skin observation completed on 06/26/23 by a RN, however the skin observation lacked documented evidence the resident had a wound. The RN explained Resident #4 had a wound on the right forearm for a few weeks. Licensed nurses tended to the wound by applying a saline solution to the wound and a band-aid. The RN explained no physician orders could be located to treat Resident 4's wound and confirmed the resident's wound was not identified on the weekly skin assessments. On 06/28/23 at 2:57 PM, the DON verbalized licensed nurses completed skin assessments for residents every week. The skin assessments documented significant bruising, rashes and/or wounds. The assessments were completed by observing the residents body and documented the type of wound and location of the wound. Once a wound was identified, physician orders would be obtained to care for the wound and the wound would be care planned. The DON confirmed Resident #4 lacked an accurate weekly skin assessment identifying the resident's wound on the right forearm. The DON observed the wound and verbalized not being aware of the wound. The DON verbalized the DON would complete a skin evaluation, create a care plan for the wound and obtain physician orders to treat the wound. The facility policy titled Skin Integrity, last updated October 2022, documented residents skin were evaluated weekly with a licensed nurse completing a full body skin audit. If a wound was identified, the wound would be documented in the residents chart, the doctor would be notified and proper wound care would be applied to the resident to treat the wound.

Based on observation, interview, record review and document review, the facility failed to ensure orders for pressure relieving and repositioning interventions to prevent a resident from developing pressure ulcers and to prevent pressure related wounds from worsening were communicated to the responsible staff. This resulted in facility-acquired pressure wounds and worsening of wounds for one discharged resident (Resident #1) and 1 of 7 active sampled residents with pressure related wounds or injuries (Resident #4). Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission assessment, dated 12/16/19, documented Resident #1 had no pressure ulcers or injuries upon admission. The assessment indicated the resident was at risk of developing pressure ulcers or injuries. A Skin and Wound Evaluation (SWE), dated 1/31/20, documented Resident #1 had an unstageable pressure wound on the left heel. Documentation indicated the wound was acquired in the facility during the previous month. The SWE lacked measurements for the left heel wound. A 2/19/20 SWE documented Resident #1's left heel wound measured 4.6 centimeters (cm) x 4.3 cm. There was no depth documented. treatment for [REDACTED]. The 2/19/20 SWE documented Resident #1 had Moisture Associated Skin Damage (MASD) of the sacrum. The wound was acquired in the facility and had been present for an unknown amount of time. The wound measured 17.1 cm x 17.0 cm. There was no depth documented. treatment for [REDACTED]. A 2/21/20 SWE documented Resident #1 had a diabetic wound on the right calf. The wound was acquired in the facility and had been present for an unknown amount of time. The wound measured 1.3 cm x 1.5 cm. There was no depth documented. The 2/21/20 SWE documented Resident #1 had a wound on the left foot, first digit. The wound was acquired in the facility and had been present for an unknown amount of time. The wound measured 0.9 cm x 1.2 cm. There was no depth documented. treatment for [REDACTED]. A 2/26/20 SWE documented the diabetic wound on Resident #1's right calf measured 2.9 cm x 2.9 cm. There was no depth documented. treatment for [REDACTED]. A physician order, dated 3/27/20, documented to turn Resident #1 every two hours and check to ensure blow up boots were on for treatment of [REDACTED]. A Care Plan for Resident #1, dated 3/27/20, documented the resident was at risk for pressure ulcers and diabetic ulcers due to limited mobility and difficulty making needs known. The documented interventions included repositioning the resident every two hours. On the MDS Kardex Report for Resident #1, the turning and repositioning program was not selected under the area for Skin and Ulcer Treatment. A Skin/Wound note, dated 3/27/20, documented orders had been received for Resident #1 to be on a strict turning schedule. A Podiatry Specialist Consultation Note, dated 4/17/20, documented Resident #1 was in constant, severe pain in bilateral lower extremities with multiple necrotic dry and wet ulcerations. The resident's pulses were not palpable in both lower extremities. Both lower extremities had a prolonged capillary refill of greater than three seconds. Resident #4 Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission assessment, dated 9/12/19, documented Resident #4 had no pressure ulcers or injuries on admission but was at risk for developing pressure/ulcer injuries. A Care Plan for Resident #4, dated 1/17/20, documented the resident had a self-care performance deficit with activities of daily living. The resident required extensive assistance of two staff to turn and reposition in bed. A nursing skin/wound progress note, dated 1/23/20, documented Resident #4 would require staff assistance to reposition. A nursing skin/wound progress note, dated 2/13/20, documented Resident #4 was unable to turn self on side. A Nurse Practitioner (NP) progress note, dated 9/17/20, documented the Resident #4 had a worsening pressure ulcer over the left ischium, had developed a new ulcer below the left ischium and over the coccyx and a suspected deep tissue injury (DTI). The resident was instructed to turn every two hours and as needed. A physician order, dated 9/17/20, documented to turn Resident #4 every two hours per resident's tolerance for pressure relief. A 9/21/20 NP progress note documented Resident #4's Stage 2 pressure ulcer over the left ischium had worsened to a Stage 3. The resident had a Stage 2 pressure ulcer over the coccyx and a suspected DTI over the right ischium. The resident was advised to turn every two hours and as needed. A 10/6/20 NP progress note documented Resident #4 was advised to turn every two hours and as needed. The resident demonstrated difficulty turning due to poor upper body strength. The resident had worsening Stage 3 pressure ulcers over the left ischium and below the left ischium, a Stage 2 pressure ulcer over the coccyx and a possible DTI over the right ischium. The Treatment Administration Record (TAR) for October 2020, documented to turn Resident #4 every two hours. The nursing staff documented on the TAR once on each shift for a total of three times daily. On 10/14/20 at 11:54 AM, a Certified Nursing Assistant (CNA) was unable to locate an area in the electronic health record (EHR) where the CNA would document when a resident was turned or repositioned. The CNA verbalized this information would need to be documented in a progress note to be communicated to the nurse. The CNA verbalized never having documented in a progress note, the turning or repositioning a resident. The CNA verbalized not being able to see the interventions from a nursing care plan in the EHR. The CNA verbalized not having received training on turning residents every two hours. On 10/14/20 at 1:29 PM, a Registered Nurse (RN) verbalized the nurse was responsible for informing the CNA when a resident needed assistance with bed mobility. The RN verbalized if a resident needed turning assistance the nurse would ask the resident if the resident would like to be turned when the nurse checked on the resident and would encourage the resident to use the call light for turning assistance. The RN stated the nurse would have to verbally inform the CNA if the nursing care plan indicated the CNA was responsible for turning the resident every two hours. The RN verbalized resident turns were not documented and the nurse would not have a way of knowing the specific time a resident was turned and nurses would not have known when a resident was last turned prior to the start of the shift unless this information was provided in report. The RN verbalized this information was not a standard part of the nursing shift report. On 10/14/20 at 3:10 PM, a RN verbalized the belief the CNA was able to see the interventions from the nursing care plan and the CNA would be able to find the interventions the CNA was responsible for by reviewing the nursing care plan. On 10/14/20 at 3:23 PM, the Director of Nursing (DON) verbalized the CNA tasks assigned in the nursing care plan would not automatically populate into the CNA service plan and CNAs were unable to access the nursing care plan interventions. On 10/14/20 at 5:00 PM, the DON and the Administrator verbalized Resident #1 and Resident #4 did not have any documentation from the CNAs regarding turning and repositioning of the residents. The DON and the Administrator verbalized there was no place in the electronic health record or a paper form for the CNA to document when a resident was turned. The facility policy Skin Integrity dated 05/2019, documented if a resident was admitted with or developed a skin ulcer/pressure ulcer/wound, care would be provided to treat, heal and prevent further development of skin ulcers/pressure ulcers/wounds. Interventions would be identified to promote healing/resolution of skin impairment. Complaint #NV 143

Based on observation, interview, document review and clinical record review the facility failed to ensure a resident received intravenous (IV) fluids as ordered by a physician for 1 of 1 resident (Resident #31). Findings include: Resident #31 Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A progress note, written by the Advanced Registered Nurse Practitioner (ARNP), dated 11/13/19 at 1:29 PM, documented Resident #31 expressed not feeling well for a couple of days and Resident #31 had a decreased appetite. A progress note dated 11/15/19 at 1:49 AM, documented Licensed Practical Nurse (LPN) #1 was unable to obtain a urine sample due to no urine output. A progress note dated 11/15/19 at 2:23 AM, documented LPN #2 was unable to start an IV line. A progress note by the ARNP, dated 11/15/19 at 12:29 PM, documented the IV fluids were ordered for immediate administration (STAT) on 11/14/19 for hydration due to Resident #31 having decreased oral intake had not been given and LPN #3 had expressed to the ARNP it was because an IV pump was not available. Resident #31's clinical record lacked documented evidence the ARNP was notified Resident #31 had no urinary output, or the IV fluids, and the UA were not completed as ordered. A progress note written by the ARNP, dated 11/18/19 at 1:18 PM, documented Resident #31 was experiencing crackles at the bases of both lungs and had audible gurgling. On 11/14/19, the ARNP had ordered one liter of IV fluid and a urinalysis with a culture but both were not completed as ordered. The ARNP documented the resident had worsening pneumonia, decreased mental status, and lethargy. Resident #31's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On 03/02/20 at 10:52 AM, the ARNP verbalized the ARNP was not notified Resident #31 had not received the IV fluids STAT until the ARNP asked LPN #3 about it the next day. The ARNP confirmed the ARNP had not been notified by nursing staff Resident #31 had no urine output on 11/15/19. The ARNP verbalized Resident #31 would have been sent to the emergency room immediately after the ARNP was notified because the resident had a history of [REDACTED]. The ARNP confirmed the IV fluids ordered STAT on 11//14/19 were not administered until 11/15/19. The ARNP verbalized STAT orders should be done right now and notification to the practitioner of an inability to complete an order should have been completed within one or two hours. On 03/04/20 at 1:49 PM, the Regional Director of Nursing verbalized STAT was defined as immediately and no medication or fluids ordered STAT should wait for twenty-four hours before being administered. The facility policy titled Medication Ordering and Receiving From Pharmacy Provider, dated 01/20, documented STAT medications that were available onsite would be administered from onsite stock prior to the next pharmacy delivery. The facility policy titled Administration of IV Fluids and Medications, dated 08/16, documented continuous IV fluids could be administered by flow regulator tubing until a pump arrived from the pharmacy. A facility policy titled CUBEX Station Policies and Procedures, revised 09/18. Documented the CUBEX (an automated medication dispensing machine) station was to be used for emergency, first-doses, and other situations where medications were needed prior to the next scheduled pharmacy delivery. The facility Inventory on Hand, C11, dated 03/02/20, documented 0.9% Sodium Chloride was a stocked medication and available in the CUBEX machine. The facility Inventory on Hand, C11, dated 03/02/20, documented IV rate flow regulator (Dial A Flo) was a stocked item and available in the CUBEX machine. The facility care path titled Change in Condition: When to report to the MD/NP/PA, dated 2003, documented that any marked change unrelieved by measures prescribed with an acute or sudden onset were to be reported immediately. The facility form titled Interact 4.0 SBAR communication Form, dated 2014, documented decreased urine output as a reportable change in condition. The facility lacked documented evidence of a definition that included specified timeframes for a STAT administration of medication. Complaint #NV 417

Based on interview, clinical record review and document review, the facility failed to ensure high risk medications were administered timely for 10 of 46 residents (Resident #18, #12, #17, #4, #5, #32, #35, #26, #34, and #33). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medication order for Resident #18, dated 02/08/20, documented: - [MEDICATION NAME] Sod-Tazobactam So Solution Reconstituted 4.5 grams, use 4.5 grams intravenously every six hours for open wound/culture results pending for bacterial infection. The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] Sod-Tazobactam So Solution Reconstituted 4.5 grams was scheduled to be administered on 02/17/20 at 7:00 AM and was administered at 12:03 PM. - [MEDICATION NAME] Sod-Tazobactam So Solution Reconstituted 4.5 grams was scheduled to be administered on 02/18/20 at 7:00 AM and was administered at 9:15 AM. A medication order for Resident #18, dated 02/07/20, documented: - [MEDICATION NAME] HCl Solution 1000 milligrams (mg)/milliliter (ml), use 1000 mg intravenously every eight hours related to pressure ulcer of right buttock, stage 4. The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] HCl Solution 1000mg/ml was scheduled to be administered on 02/17/20 at 8:00 AM and was administered at 12:03 PM. - [MEDICATION NAME] HCl Solution 1000 mg/10 ml was scheduled to be administered on 02/18/20 at 8:00 AM and was administered at 10:38 AM. - [MEDICATION NAME] HCL Solution 1000 mg/10 ml was scheduled to be administered on 02/18/20 at 4:00 PM and was administered at 7:52 PM. A medication order for Resident #18, dated 02/10/20, documented: - [MEDICATION NAME] tablet 800 mg give one tablet by mouth every four hours related to neuralgia and neuritis. The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] Tablet 800 mg was scheduled to be administered on 02/17/20 at 8:00 AM and was administered at 12:03 PM. - [MEDICATION NAME] Tablet 800 mg was scheduled to be administered on 02/18/20 at 4:00 PM and was administered at 7:52 PM. - [MEDICATION NAME] Tablet 800 mg was scheduled to be administered on 02/22/20 at 8:00 AM and was administered at 10:04 AM. - [MEDICATION NAME] Tablet 800 mg was scheduled to be administered on 02/25/20 at 8:00 AM and was administered at 10:37 AM. - [MEDICATION NAME] Tablet 20 mg was scheduled to be administered on 02/29/20 at 4:00 PM and was administered at 6:05 PM. A medication order for Resident #18, dated 02/07/20, documented: - [MEDICATION NAME] tablet 20 mg give 1 tablet by mouth every four hours for musculoskeletal therapy agents/muscle spasms and pain. The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] Tablet 20 mg was scheduled to be administered on 02/17/20 at 8:00 AM and was administered at 12:03 PM. - [MEDICATION NAME] Tablet 20 mg was scheduled to be administered on 02/18/20 at 4:00 PM and was administered at 7:52 PM. - [MEDICATION NAME] Tablet 20 mg was scheduled to be administered on 02/22/20 at 8:00 AM and was administered at 10:04 AM. - [MEDICATION NAME] Tablet 20 mg was scheduled to be administered on 02/25/20 at 8:00 AM and was administered at 10:37 AM. On 03/04/20 at 3:22 PM, Resident #18 verbalized medications were frequently administered late. The resident verbalized being most aware of the [MEDICATION NAME] and [MEDICATION NAME] being administered late. The resident verbalized when the [MEDICATION NAME] and [MEDICATION NAME] were given late the resident experienced muscle spasms and nerve pain. The resident verbalized when the [MEDICATION NAME] was given late the resident's pain would increase to an 11 out of 10 on a scale of one to 10. The resident verbalized when the resident's pain became greater than an 8 out of 10 it could take several hours before the resident's pain was at a level the resident considered bearable. Resident #12 Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A medication order for Resident #12, dated 02/21/20, documented: - Meropenem Solution Reconstituted 1 gram, use 1 gram intravenously every 12 hours for extended spectrum beta-lactamases (ESBL) in the urine for 14 days. A medication order for Resident #12, dated 03/01/20, documented: - Meropenem Solution Reconstituted 1 gram, use 1 gram intravenously every 12 hours for ESBL in the urine for 14 days. The medication administration audit report, dated 02/17/20-03/01/20, documented: - Meropenem 1 gram was scheduled to be administered on 02/25/20 at 8:00 AM and was administered on 02/25/20 at 10:28 AM. - Meropenem 1 gram was scheduled to be administered on 03/01/20 at 8:00 PM and was missed. On 03/04/20 at 3:15 PM, Resident #12 verbalized the resident's antibiotics were sometimes administered late. The resident verbalized the resident was never given an explanation for the late administration but the resident felt angry because the resident knew the resident needed the antibiotics to get better and the late administration meant the resident's needs were not important to the staff. Resident #17 Resident #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A medication order for Resident #17, dated 12/20/19, documented: - Humalog Solution 100 unit/ml inject as per sliding scale subcutaneously before meals and at bedtime for diabetes mellitus. The medication administration audit report, dated 02/17/20-03/01/20, documented: - Humalog Insulin was scheduled to be administered on 02/17/20 at 4:00 PM and was administered at 6:52 PM. - Humalog Insulin was scheduled to be administered on 02/17/20 at 8:00 PM was administered at 10:22 PM. - Humalog Insulin was scheduled to be administered on 02/19/20 at 4:00 PM and was administered at 6:34 PM. - Humalog Insulin was scheduled to be administered on 02/21/20 at 4:00 PM and was administered at 7:04 PM. - Humalog Insulin was scheduled to be administered on 02/21/20 at 8:00 PM and was administered at 10:16 PM - Humalog Insulin was scheduled to be administered on 02/23/20 at 8:00 PM and was administered at 11:26 PM. - Humalog Insulin was scheduled to be administered on 02/26/20 at 4:00 PM and was administered at 6:50 PM. - Humalog Insulin was scheduled to be administered on 02/26/20 at 8:00 PM and was administered at 10:27 PM. - Humalog Insulin was scheduled to be administered on 02/28/20 at 8:00 PM and was administered at 10:41 PM. - Humalog Insulin was scheduled to be administered on 02/26/20 at 5:00 AM and was missed. A medication order for Resident #17, dated 07/30/18, documented: - [MEDICATION NAME] Acid capsule 250 mg give 2 capsules by mouth one time a day related to [MEDICAL CONDITION]. The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] Acid 500 mg was scheduled to be administered on 02/17/20 at 8:00 PM and was administered at 10:31 PM. - [MEDICATION NAME] Acid 500 mg was scheduled to be administered on 02/21/20 at 8:00 PM and was administered at 10:09 PM. - [MEDICATION NAME] Acid 500 mg was scheduled to be administered on 02/23/20 at 8:00 PM and was administered at 11:22 PM. - [MEDICATION NAME] Acid 500 mg was scheduled to be administered on 02/26/20 at 8:00 PM and was administered at 10:29 PM. - [MEDICATION NAME] acid 500 mg was scheduled to be administered on 02/28/20 at 8:00 PM and was administered at 10:44 PM. - [MEDICATION NAME] Acid 500 mg was scheduled to be administered on 03/01/20 at 8:00 PM and was administered at 10:35 PM. A medication order for Resident #17, dated 07/24/19, documented: - [MEDICATION NAME] HCl tablet 5 mg, give 1 tablet by mouth two times a day for chronic pain. The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] 5 mg was scheduled to be administered on 02/17/20 at 8:00 PM and was administered at 10:35 PM. - [MEDICATION NAME] 5 mg was scheduled to be administered on 02/21/20 at 8:00 PM and was administered at 10:12 PM. - [MEDICATION NAME] 5 mg was scheduled to be administered on 02/23/20 at 8:00 PM and was administered at 11:25 PM. - [MEDICATION NAME] 5 mg was scheduled to be administered on 02/26/20 at 5:00 AM and was missed. - [MEDICATION NAME] 5 mg was scheduled to be administered on 02/26/20 at 8:00 PM and was administered at 10:31 PM. - [MEDICATION NAME] 5 mg was scheduled to be administered on 02/28/20 at 8:00 PM and was administered at 10:49 PM. - [MEDICATION NAME] 5 mg was scheduled to be administered on 03/01/20 at 8:00 PM and was administered at 10:39 PM. Resident #4 Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4 physician order [REDACTED]. Give 5 mg by mouth once a day related to unspecified dementia without behavioral disturbance. The Medication Administration Audit Report documented Resident #4 was administered [MEDICATION NAME] 5 mg tablet administration time on the following days: -February 22, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 9:40 PM. -February 23, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:33 PM. -February 24, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 12:02 AM. -February 25, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:07 PM. -February 26, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:27 PM. Resident #4's physician order [REDACTED]. Give 0.1 mg by mouth once a day related to orthostatic [MEDICAL CONDITION]. The Medication Administration Audit Report documented Resident #4 was administered fludrocortisone acetate tablet 0.1 mg administration time on the following days: -February 24, 2020, fludrocortisone acetate was scheduled to be administered at 8:00 AM and was not administered until 2:25 PM. -February 28, 2020, fludrocortisone acetate was scheduled to be administered at 8:00 AM and was not administered until 10:53 AM. -February 29, 2020, fludrocortisone acetate was scheduled to be administered at 8:00 AM and was not administered until 10:22 AM. -March 1, 2020, fludrocortisone acetate was scheduled to be administered at 8:00 AM and was not administered until 10:25 AM. Resident #4's physician order [REDACTED]. Give 5 mg by mouth two times a day for dementia. The Medication Administration Audit Report documented Resident #4 was administered memantine HCI tablet 5 mg administration time on the following days: -February 24, 2020, memantine HCI was scheduled to be administered at 7:00 AM and was not administered until 2:27 PM. -February 24, 2020, memantine HCI was scheduled to be administered at 7:00 PM and was not administered until 12:02 AM. -February 28, 2020, memantine HCI was scheduled to be administered at 7:00 AM and was not administered until 3:54 PM. -February 29, 2020, memantine HCI was scheduled to be administered at 7:00 AM and was not administered until 1:34 PM. Resident #4's physician order [REDACTED]. Give 0.5 mg by mouth two times a day related to tumor. The Medication Administration Audit Report documented Resident #4 was administered ropinirole HCI tablet 0.5 mg administration time on the following days: -February 20, 2020, ropinirole HCI was scheduled to be administered at 4:00 PM and was not administered until 9:40 PM. -February 22, 2020, ropinirole HCI was scheduled to be administered at 4:00 PM and was not administered until 6:33 PM. -February 24, 2020, ropinirole HCI was scheduled to be administered at 4:00 PM and was not administered until 12:02 AM. -February 24, 2020, ropinirole HCI was scheduled to be administered at 8:00 AM and was not administered until 2:26 PM. -February 25, 2020, ropinirole HCI was scheduled to be administered at 4:00 PM and was not administered until 6:07 PM. -February 26, 2020, ropinirole HCI was scheduled to be administered at 4:00 PM and was not administered until 6:28 PM. -February 28, 2020, ropinirole HCI was scheduled to be administered at 8:00 AM and was not administered until 10:55 PM. -February 29, 2020, ropinirole HCI was scheduled to be administered at 8:00 AM and was not administered until 10:23 AM. -March 1, 2020, ropinirole HCI was scheduled to be administered at 8:00 AM and was not administered until 10:26 AM. Resident #4's physician order [REDACTED]. Give 10 mg by mouth three times a day for orthostatic hypertension. The Medication Administration Audit Report documented Resident #4 was administered [MEDICATION NAME] HCI 5 mg tablet administration time on the following days: -February 20, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 9:40 PM. -February 21, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 12:00 PM and was not administered until 4:26 PM. -February 22, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 6:33 PM. -February 24, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 2:25 PM. -February 24, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 12:02 AM. -February 25, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 6:27 PM. -February 28, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:55 AM. -February 28, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 12:00 PM and was not administered until 2:25 PM. -February 29, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:36 AM. -February 29, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 12:00 PM and was not administered until 2:05 PM. Resident #4's physician order [REDACTED]. Give one tablet by mouth once a day for [MEDICAL CONDITION]. The Medication Administration Audit Report documented Resident #4 was administered [MEDICATION NAME] 5 mg tablet administration time on the following days: -February 20, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:33 PM. -February 22, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:33 PM. -February 24, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 12:02 AM. -February 25, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:07 PM. -February 26, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:28 PM. -March 1, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:26 AM. Resident #4's physician order [REDACTED]. Give one capsule by mouth every 6 hours for recurrent [MEDICAL CONDITION] (C. Diff) for 14 days. The Medication Administration Audit Report documented Resident #4 was administered [MEDICATION NAME] HCI 125 mg capsule more than two hours late from the original administration time on the following days: -February 26, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 PM and was not administered until 2:12 AM. -February 28, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:55 AM. -February 29, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:37 AM. -February 27, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 2:00 AM and was not administered until 4:49 AM. -March 1, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:26 AM. Resident #5 Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #5's physician order [REDACTED]. Give 10 mg by mouth one time a day for hypertension. The Medication Administration Audit Report documented Resident #5 was administered [MEDICATION NAME] 10 mg tablet administration time on the following days: -February 17, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:05 AM. -February 19, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:27 AM. -February 22, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 11:43 AM. -February 24, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:09 AM. -February 25, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 11:47 AM. -February 26, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:17 AM. -February 27, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:40 AM. -March 1, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 12:41 PM. Resident #5's physician order [REDACTED]. Give 10 mg by mouth three times a day for spasms/pain. The Medication Administration Audit Report documented Resident #5 was administered [MEDICATION NAME] HCI 10 mg tablet administration time on the following days: -February 17, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:06 AM. -February 17, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 6:56 PM. -February 18, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 6:21 PM. -February 19, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:27 AM. -February 19, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 7:32 PM. -February 20, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 7:35 PM. -February 21, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 12:00 PM and was not administered until 3:06 PM. -February 21, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 6:53 PM. -February 22, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 8:03 PM. -February 24, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:09 AM. -February 25, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 11:47 AM. -February 26, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:17 AM. -February 26, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 6:40 PM. -February 27, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 10:40 AM. -February 27, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 10:47 PM. -February 28, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 1:25 PM. -February 28, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 10:40 PM. -March 1, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 8:00 AM and was not administered until 12:51 PM. -March 1, 2020, [MEDICATION NAME] HCI was scheduled to be administered at 4:00 PM and was not administered until 6:51 PM. Resident #5's physician order [REDACTED]. Give 100 mg by mouth two times a day for hypertension. The Medication Administration Audit Report documented Resident #5 was administered [MEDICATION NAME] 100 mg tablet administration time on the following days: -February 17, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:05 AM. -February 17, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:56 PM. -February 18, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:21 PM. -February 19, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:27 AM. -February 19, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 7:32 PM. -February 20, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 7:35 PM. -February 21, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:53 PM. -February 22, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 11:43 AM. -February 22, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 8:03 PM. -February 24, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:09 AM. -February 25, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 11:47 AM. -February 25, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 7:36 PM. -February 26, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:17 AM. -February 26, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:40 PM. -February 27, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 10:40 AM. -February 27, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 10:47 PM. -February 28, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 1:24 PM. -February 28, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 10:40 PM. -March 1, 2020, [MEDICATION NAME] was scheduled to be administered at 8:00 AM and was not administered until 12:51 PM. -March 1, 2020, [MEDICATION NAME] was scheduled to be administered at 4:00 PM and was not administered until 6:51 PM. Resident #32 Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].>- Carvedilol Tablet 3.125 mg give 1 tablet by mouth two times a day related to hypertension. The medication administration audit report, dated 02/17/20-03/01/20, documented: - Carvedilol Tablet 3.125 mg was scheduled to be administered on 02/20/20 at 8:00 PM and was administered at 10:03 PM. - Carvedilol Tablet 3.125 mg was scheduled to be administered on 02/22/20 at 8:00 PM and was administered at 10:45 PM. - Carvedilol Tablet 3.125 mg was scheduled to be administered on 02/24/20 at 8:00 PM and was administered at 12:06 AM on 02/25/20. - Carvedilol Tablet 3.125 mg was scheduled to be administered on 02/25/20 at 8:00 PM and was administered at 10:09 PM. - Carvedilol Tablet 3.125 mg was scheduled to be administered on 02/28/20 at 8:00 AM and was administered at 10:24 AM. - Carvedilol Tablet 3.125 mg was scheduled to be administered on 02/28/20 at 8:00 PM and was administered at 10:02 PM. - Carvedilol Tablet 3.125 mg was scheduled to be administered on 02/29/20 at 8:00 AM and was administered at 10:18 AM. - Carvedilol Tablet 3.125 mg was scheduled to be administered on 03/01/20 at 8:00 AM and was administered at 10:20 AM. A physician order [REDACTED].>- [MEDICATION NAME] Capsule 100 mg, give 1 capsule by mouth two times a day for [MEDICAL CONDITION] The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] Capsule 100 mg was scheduled to be administered on 02/20/20 at 8:00 PM and was administered at 10:03 PM. - [MEDICATION NAME] Capsule 100 mg was scheduled to be administered on 02/22/20 at 8:00 PM and was administered at 10:45 PM. - [MEDICATION NAME] Capsule 100 mg was scheduled to be administered on 02/24/20 at 8:00 PM and was administered on 02/25/20 at 12:06 AM. - [MEDICATION NAME] Capsule 100 mg was scheduled to be administered on 02/25/20 at 8:00 PM and was administered at 10:09 PM. - [MEDICATION NAME] Capsule 100 mg was scheduled to be administered on 02/28/20 at 8:00 AM and was administered at 10:24 AM. - [MEDICATION NAME] Capsule 100 mg was scheduled to be administered on 02/28/20 at 8:00 PM and was administered at 10:02 PM. - [MEDICATION NAME] Capsule 100 mg was scheduled to be administered on 02/29/20 at 8:00 AM and was administered at 10:18 AM. - [MEDICATION NAME] Capsule 100 mg was scheduled to be administered on 03/01/20 at 8:00 AM and was administered at 10:20 AM. - [MEDICATION NAME] Capsule 100 mg was scheduled to be administered on 02/29/20 at 8:00 AM and was administered at 10:18 AM. A physician order [REDACTED].>- [MEDICATION NAME] HCL Tablet 100 mg give 1 tablet by mouth two times a day for tremors. The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] HCL Tablet 100 mg was scheduled to be administered on 02/20/20 at 8:00 PM and was administered at 10:03 PM. - [MEDICATION NAME] HCL Tablet 100 mg was scheduled to be administered on 02/22/20 at 8:00 PM and was administered at 10:45 PM. - [MEDICATION NAME] HCL Tablet 100 mg was scheduled to be administered on 02/24/20 at 8:00 PM and was administered on 02/25/20 at 12:06 AM. - [MEDICATION NAME] HCL Tablet 100 mg was scheduled to be administered on 02/25/20 at 8:00 PM and was administered at 10:09 PM - [MEDICATION NAME] HCL Tablet 100 mg was scheduled to be administered on 02/28/20 at 8:00 AM and was administered at 10:24 AM. - [MEDICATION NAME] HCL Tablet 100 mg was scheduled to be administered on 02/28/20 at 8:00 PM and was administered at 10:02 PM. - [MEDICATION NAME] HCL Tablet 100 mg was scheduled to be administered on 02/29/20 at 8:00 AM and was administered at 10:18 AM. - [MEDICATION NAME] HCL Tablet 100 mg was scheduled to be administered on 03/01/20 at 8:00 AM and was administered at 10:18 AM. A physician order [REDACTED].>- [MEDICATION NAME] Tablet 10 mg give 1 tablet by mouth one time a day for hypertension. The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] Tablet 10 mg was scheduled to be administered on 02/28/20 at 8:00 AM and was administered at 10:24 AM. - [MEDICATION NAME] Tablet 10 mg was scheduled to be administered on 02/29/20 at 8:00 AM and was administered at 10:18 AM. - [MEDICATION NAME] Tablet 10 mg was scheduled to be administered on 03/01/20 at 8:00 AM and was administered at 10:20 AM. Resident #35 Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].>- Apixaban Tablet give 5 mg by mouth two times a day for [MEDICAL CONDITION] prevention. The medication administration audit report, dated 02/17/20-03/01/20, documented: - Apixaban 5 mg was scheduled to be administered on 02/17/20 at 7:00 AM and was administered at 11:02 AM. - Apixaban 5 mg was scheduled to be administered on 02/25/20 at 8:00 AM and was administered at 10:11 AM. - Apixaban 5 mg was scheduled to be administered on 02/28/20 at 8:00 AM and was administered at 12:34 PM. - Apixaban 5 mg was scheduled to be administered on 03/01/20 at 8:00 AM and was administered at 10:49 AM. A physician order [REDACTED].>- [MEDICATION NAME] Sodium Solution reconstituted 1-gram (1 gm) use 1000 mg intravenously (IV) three times a day for septic joint. Administer IV every 8 hours until 04/01/20 The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] Sodium Solution 1 gm was scheduled to be administered on 02/25/20 at 8:00 AM and was administered at 10:11 AM. - [MEDICATION NAME] Sodium Solution 1 gm was scheduled to be administered on 02/27/20 at 8:00 AM and was administered at 11:59 AM. - [MEDICATION NAME] Sodium Solution 1 gm was scheduled to be administered on 02/27/20 at 8:00 PM and was administered at 10:30 PM. - [MEDICATION NAME] Sodium Solution 1 gm was scheduled to be administered on 02/28/20 at 8:00 PM and was administered at 11:15 PM. - [MEDICATION NAME] Sodium Solution 1 gm was scheduled to be administered on 03/01/20 at 8:00 AM and was administered at 10:59 AM. A physician order [REDACTED].>- [MEDICATION NAME] SR Tablet Extended Release (ER) 12 hour 150 give 150 mg by mouth two times daily for depression. The medication administration audit report, dated 02/17/20-03/01/20, documented: - [MEDICATION NAME] SR tablet ER 150 mg was scheduled to be administered on 02/17/20 at 9:00 AM and was administered at 11:01 AM. A physician order [REDACTED].>- Duloxetine HCL Capsule Delayed Release Particles 20 mg give one capsule by mouth one time a day for [MEDICAL CONDITION]. The medication administration audit report, dated 02/17/20-03/01/20, documented: - Duloxetine HCL Capsule was scheduled to be administered on 02/25/20 at 8:00 AM and was administered at 10:12 AM. - Duloxetine HCL Capsule was scheduled to be administered on 02/28/20 at 8:00 AM and was administered at 12:34M. - Duloxetine HCL Capsule was scheduled to be administered on 03/01/20 at 8:00 AM and was administered at 10:49 AM. A physician order [REDACTED].>- Calorie Dense Medication Pass three times a day 60 milliliters (ml) related to weight loss. The medication administration audit report, dated 02/17/20-03/01/20, documented: - Calorie Dense Medication Pass 60 ml was scheduled to be administered on 02/25/20 at 8:00 AM and was administered at 10:09 AM. - Calorie Dense Medication Pass 60 ml was scheduled to be administered on 02/28/20 at 8:00 AM and was administered at 11:59 AM. - Calorie Dense Medication Pass 60 ml was scheduled to be administered on 02/28/20 at 4:00 PM and was administered at 6:42 PM. - Calorie Dense Medication Pass

Based on observation and staff interview the facility failed to ensure the residents' call light system was fully operational on all nursing units. Findings include: The facility failed to ensure the nurses' station on the 20-bed Advantage Wing (of a 120-bed facility) was equipped with a functioning audible call system through the communication system from resident rooms and toileting/bathing areas. This affected the current census of 17 residents residing on this wing. On 12/13/12, at 9:50 AM, while re-checking the Advantage Unit's soiled utility room, and making a general comment that concerns with the paint around the hand sink had already been addressed, the nursing assistant, who had opened the door for this surveyor indicated she wished the call light system could be fixed as quickly. When this surveyor inquired further, the nursing assistant explained, while the call lights worked in the resident areas (bed, bath and shower rooms), the sound feature on the call lights and the call light box at the Nurses' Station was not working. The nursing assistant further explained the sound to the call lights only worked inside the soiled utility room which was located at the end of the unit. The nursing assistant indicated the concern had been documented by herself, in the Unit's 24 Hour Report Log on several occasions. The nursing assistant indicated she could not recall when the problem was first discovered, but it had been quite some time ago. The nursing assistant accompanied this surveyor from the soiled utility room back to the Nurses' Station, which was at the opposite end of the unit. While at the Nurses' Station, having a staff member turn on a bedside call light in a room, it was noted while the light fixture, which was located above the door on the outside of the resident's room lit up, there was no accompanying sound. There was also no accompanying sound coming from the call light box at the Nurses' Station. With routine activity going on in the immediate area, this surveyor had to concentrate for several moments (approximately 30 to 90 seconds) to hear any sound coming from the soiled utility room. When the sound coming from the utility room could finally be heard, it was very faint and at times could not be heard. The sound coming from behind the closed soiled utility room door, had a subtle "chime" tone and chimed in approximately 35-50 second intervals. The sound was very similar and could easily be mistaken for an alarm on a infusion pump in a closed room. In interviewing several nursing assistants and staff on the unit, staff indicated they frequently did not hear the sound of the call light coming from the soiled utility room and depending on where they were located at the time, some of the residents' rooms were not always within view. Consequently the exterior call light fixture above the doors, could not be seen. After making these observations, the facility's Maintenance Supervisor (Employee #3) was interviewed. The Supervisor indicated he was aware of the problem with the call light system on the Advantage Unit, and it had been approximately 5-6 months since the problem had been identified. The Supervisor indicated he had been checking into parts for fixing the call system, but had encounter multiple problems with accessing the vendor. The Supervisor further indicated for this particular system, which was no longer in production, custom parts may be needed. The Supervisor also indicated that he thought the sound of the call light in the soiled utility room would be adequate until he could get a vendor, determine parts needed and to present an invoice to the Administrator for corporate office approval. The Supervisor indicated he had not informed the Administrator about the problem.

Based on observation and staff interview the facility failed to ensure the residents' call light system was fully operational on all nursing units. Findings include: The facility failed to ensure the nurses' station on the 20-bed Advantage Wing (of a 120-bed facility) was equipped with a functioning audible call system through the communication system from resident rooms and toileting/bathing areas. This affected the current census of 17 residents residing on this wing. On 12/13/12, at 9:50 AM, while re-checking the Advantage Unit's soiled utility room, and making a general comment that concerns with the paint around the hand sink had already been addressed, the nursing assistant, who had opened the door for this surveyor indicated she wished the call light system could be fixed as quickly. When this surveyor inquired further, the nursing assistant explained, while the call lights worked in the resident areas (bed, bath and shower rooms), the sound feature on the call lights and the call light box at the Nurses' Station was not working. The nursing assistant further explained the sound to the call lights only worked inside the soiled utility room which was located at the end of the unit. The nursing assistant indicated the concern had been documented by herself, in the Unit's 24 Hour Report Log on several occasions. The nursing assistant indicated she could not recall when the problem was first discovered, but it had been quite some time ago. The nursing assistant accompanied this surveyor from the soiled utility room back to the Nurses' Station, which was at the opposite end of the unit. While at the Nurses' Station, having a staff member turn on a bedside call light in a room, it was noted while the light fixture, which was located above the door on the outside of the resident's room lit up, there was no accompanying sound. There was also no accompanying sound coming from the call light box at the Nurses' Station. With routine activity going on in the immediate area, this surveyor had to concentrate for several moments (approximately 30 to 90 seconds) to hear any sound coming from the soiled utility room. When the sound coming from the utility room could finally be heard, it was very faint and at times could not be heard. The sound coming from behind the closed soiled utility room door, had a subtle chime tone and chimed in approximately 35-50 second intervals. The sound was very similar and could easily be mistaken for an alarm on a infusion pump in a closed room. In interviewing several nursing assistants and staff on the unit, staff indicated they frequently did not hear the sound of the call light coming from the soiled utility room and depending on where they were located at the time, some of the residents' rooms were not always within view. Consequently the exterior call light fixture above the doors, could not be seen. After making these observations, the facility's Maintenance Supervisor (Employee #3) was interviewed. The Supervisor indicated he was aware of the problem with the call light system on the Advantage Unit, and it had been approximately 5-6 months since the problem had been identified. The Supervisor indicated he had been checking into parts for fixing the call system, but had encounter multiple problems with accessing the vendor. The Supervisor further indicated for this particular system, which was no longer in production, custom parts may be needed. The Supervisor also indicated that he thought the sound of the call light in the soiled utility room would be adequate until he could get a vendor, determine parts needed and to present an invoice to the Administrator for corporate office approval. The Supervisor indicated he had not informed the Administrator about the problem.