Every finding on record at Pahrump Health and Rehabilitation

Based on observation, interview, record review and document review the facility failed to ensure the physician ordered dressing changes for a midline catheter (a small flexible tube inserted into a vein of the upper arm) for 1 of 33 sampled residents (Resident 84). The deficient practice had the potential for the midline catheter to become infected due to the dressing not being changed.Findings include:Resident 84 (R84) was admitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, urinary tract infection, and acute kidney failure. On 12/16/2025 at 11:22 AM, R84 was lying in bed with a midline catheter in the upper left arm. The midline dressing was not dated.A Physician Order dated 11/27/2025 documented may insert midline for intravenous (IV) antibiotics. R84's medical record lacked a physician order for midline dressing changes. On 12/17/2025 at 12:18 PM, a Licensed Practical Nurse (LPN) explained residents with IV lines would have the dressing changed within the first 24 hours of admission and then every seven days after. The LPN explained R84 was scheduled to have midline dressing changes on Sundays. The LPN confirmed R84's midline dressing was not dated and reviewed R84's medical record and confirmed no documentation the dressing was changed. The LPN explained was unable to determine when the midline dressing was last changed. On 12/17/2025 at 3:07 PM, the Director of Nursing (DON) explained midline dressing changes would be completed within 24 hours of admission and every seven days following. The DON reviewed R84's medical record and confirmed there was no order for midline dressing changes. The facility policy titled Vascular Access Devices and Infusion Therapy Procedures, dated 2011, documented transparent membrane dressings for midlines were changed at a minimum frequency of every seven days and as necessary (PRN).

Based on observation, interview, record review, and document review, the facility failed to ensure 1) a smoking safety evaluation was completed to determine whether a resident was safe to smoke independently or required supervision for 1 of 33 sampled residents (Resident 39); and 2) and prevent residents or staff from smoking in the facility enclosed courtyard. The deficient practice had the potential to place residents, staff, and visitors at risk of injury related to smoking.Findings include:1) Resident 39 (R39) was admitted [DATE], readmitted [DATE], with diagnosis including paraplegia, anxiety disorder, and schizoaffective disorder. R39 was listed on the facility's smokers list.A Care Plan dated 11/30/2025, documented resident was a smoker.On 12/16/2025 at 11:22 AM, R39 reported going outside the facility grounds to smoke independently.On 12/18/2025 at 7:10 AM, R39 was observed outside, across the street from the facility, seated in a wheelchair and smoking alone without staff supervision.A Smoking Safety Evaluation dated 09/14/2025, lacked documented evidence of an interdisciplinary team (IDT) determination regarding whether the resident was safe to smoke independently or required supervision, as Section E was left blank.On 12/17/2025 at 12:54 PM, the Director of Nursing (DON), explained the facility was a non-smoking facility and residents that chose to leave the facility grounds to smoke were to have a smoking assessment and a smoking safety evaluation completed.On 12/18/2025 at 4:10 PM, the Executive Director (ED), explained the purpose of the smoking safety evaluation was to determine if R39 was safe to smoke independently. The ED acknowledged R39's smoking safety evaluation dated 09/14/2025, lacked documentation of the IDT determination regarding whether the resident was safe to smoke independently or required supervision, as the designated section was not completed.2) On 12/17/2025 at 2:20 PM, during an inspection of the facility's enclosed courtyard, the area under the patio roof which contained one table and nine chairs was observed. Fifteen cigarette butts were found on the ground, two of which were within six inches of the facility walls. Multiple burn marks were present on the cement floor next to the table, consistent with cigarettes being extinguished against the cement surface. Cigarette ashes were observed on the floor, and one empty packet of cigarettes was found in the trash bin.On 12/17/2025 at 2:38 PM, a Licensed Practical Nurse (LPN), reported that the enclosed courtyard was used by residents as well as staff during the nightshift.On 12/17/2025 in the afternoon, the Environmental Service (EVS) Director acknowledged evidence of smoking activity had previously been found in the courtyard, including smoking materials, by the staff member responsible for emptying the trash bin in the courtyard. The EVS Director explained the findings were reported to management.On 12/17/2025 at 2:48 PM, the Executive Director (ED), explained the enclosed courtyard was used by both residents and staff. The ED confirmed the cigarette butts on the ground, two of which were within 6 inches of the facility walls, the extinguished cigarette burns on the cement, and the ashes on the floor. The ED explained staff had not been observed smoking in the courtyard during the day, was aware staff used the courtyard at night, and staff may have smoked at night. The ED reported violations of the facility non-smoking policy were a continuous concern for the facility. The ED stated had received reports in the past of evidence of smoking in the courtyard by staff and residents and acknowledged the use of the courtyard for smoking posed a fire risk for the facility.A facility policy titled Resident Smoking Safety Independent and Unsupervised updated January 2025, documented it was the policy of the center to provide a safe environment for residents, staff, and visitors by limiting the use of smoking materials on its grounds. Residents who wished to smoke were evaluated for their ability to smoke safely. A Notice of Smoke-Free Center Policy Brochure, updated March 2025, documented Smoking was Prohibited in all Buildings and on Exterior Grounds. A facility policy titled Smoke-Free Center, updated February 2025, documented if a resident wanted to smoke independently off grounds and the center has knowledge of the resident's desire, the Center validates they have been evaluated to do so safely. Oxygen was not allowed in smoking areas at any time. Smokers remained at least 20 feet away from oxygen in use. Smoking including the use of e-cigarettes was prohibited for everyone on the property owned and operated by the Center, including residents, employees, visitors, volunteers, consultants, contractors, and government representatives. The policy applied to buildings, vehicles, parking lots and common outdoor areas within the boundaries of the ground.

Based on interview, record review, and document review the facility failed to communicate to the dialysis center, the need for contact precautions related to infectious dermatitis for 1 of 33 sampled residents (Resident 11). The deficient practice had the potential to place others at risk for transmission of infection. Findings include:Resident 11 (R11) was admitted to the facility on [DATE] with diagnoses including spinal stenosis of lumbar region, polyneuropathy, and end stage renal disease dependance on renal dialysis. On 12/16/2025 at 1:18 PM, R11 had rash that staff treated with medication and isolation and the resident goes to dialysis. A Physician Order, undated, documented dialysis Monday, Wednesday and Friday.A Nursing Progress note dated 11/26/2025 documented the Director of Nursing (DON) was notified of a new rash with small pustule like areas. A Physician Order dated 12/08/2025, documented contact precautions as recommended for residents known or suspected to be infected with infectious agents transmitted person to person via the direct/indirect contact route every shift for infectious dermatitis. On 12/18/2025 at 9:36 AM, a Registered Nurse (RN) explained to communicate care with the dialysis center the staff would utilize pre- dialysis assessments. The pre-dialysis assessment was printed out and sent with the resident to dialysis. The pre-dialysis assessment documented any changes in condition and if new isolation orders were received. The information would either be typed or handwritten, if there was no designated space to provide the information, on the pre-dialysis assessment.R11's pre-dialysis assessment dated [DATE] lacked documentation regarding contact isolation. On 12/18/2025 at 12:14 PM, the Director of Nursing (DON) and Infection Preventionist confirmed the dialysis center was not contacted regarding the need for contact isolation related to infectious dermatitis for R11.The facility policy titled Dialysis, updated 03/2015, documented the facility communicates with the dialysis center by completing the dialysis transfer form. The dialysis transfer form included changes in medical or mental status since last dialysis appointment. Complaint 2286702

Based on observation, interview, and document review the facility failed to ensure medication was not left unattended on top of a medication cart. The deficient practice had the potential for placing residents at risk for improper use of medication.Findings include: On 12/18/2025 at 8:12 AM, a medication bottle of fluticasone propionate nasal spray 50 micrograms (a medication used for nasal symptoms such as congestion, sneezing, runny nose, and nasal itching), was observed on top of a mediation cart in the hallway, unattended and accessible to any person walking by. The nurse was observed inside a nearby resident's room. On 12/18/2025 at 8:15 AM, a Registered Nurse (RN), confirmed had left the medication unattended on top of the medication cart and walked away to enter a resident's room. The RN acknowledged should not have left the medication unattended and accessible to all due to resident safety risks if ingested or used by a resident. On 12/18/2025 at 11:29 AM, the Director of Nursing (DON), stated medication should not have been left out unattended. The DON explained if a medication was not being used, it should have been returned to the medication cart and locked. The DON acknowledged medication left unattended posed a risk to residents if they were to access the medication.A facility policy titled Medication Storage, dated 01/2025, documented medications and biological were to be stored in a controlled environment. This may include medication carts, medication rooms, medication cabinets or other suitable containers.

Based on observation, interview, record review, and document review, the facility failed to ensure 1) the use of protective personal equipment (PPE) for 1 of 33 sampled residents (Resident 18) and 2 unsampled residents (Resident 16 and 115) on contact precautions and enhanced barrier precautions and 2) report an outbreak of infectious dermatitis to the state health authority. The deficient practice had the potential for the spread of infectious organisms.Findings include:1) On 12/17/2025 at 11:45 AM, a Certified Nursing Assistant (CNA) explained if a resident was on contact precautions, staff were to apply personal protective equipment (PPE) as listed on the signage prior to entering the resident room and remove prior to exiting the resident room. For residents that require Enhanced Barrier Precautions (EBP) the PPE would be applied when staff were providing direct care tasks for the residents. A. On 12/18/2025 at 9:28 AM, R115 had a sign posted to the left of the door which documented the following: -Contact Precautions everyone must clean hands, including before entering and when leaving the room. Providers and Staff must: put on gloves and gown before room entry and discard gloves and gown before room exit. The Director of Nursing (DON) was in R115's room wearing gloves providing resident care. The DON exited R115's room with gloves on, walked to the medication cart parked approximately 25 feet adjacent to R115's room, removed the gloves and obtained a new pair of gloves from a glove box on the side of the medication cart and returned to R115's room. On 12/19/2025 at 11:09 AM, the DON acknowledged did not follow proper use of PPE and hygiene for R115. B. On 12/18/2025 at 10:02 AM, R16 had a sign posted upon entry of room which documented the resident was on Contact Precautions. A CNA was at R16's bedside wearing no PPE. C. On 12/18/2025 at 11:22 AM, R18 had a sign posted upon entry of room which documented the following: Enhanced Barrier Precautions providers and staff must wear gloves and a gown for the following high-contact resident care activities dressing, bathing or showering, transferring, changing linens, providing personal hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, or wound care: any skin opening requiring a dressing. R18's room door was closed, upon knocking a response to enter was received. Upon opening R18's door, R18 was lying in bed and a staff member wearing gloves was noted at the side of the bed holding linens and explained was providing resident care. On 12/18/2025 at 11:29 AM, the DON and Infection Preventionist explained expectations for Enhanced Barrier Precautions was for staff to use gowns and gloves when providing direct care. For Contact Precautions the expectation was for staff to apply gloves, a gown, and a mask prior to entering the resident room. All PPE was to be removed prior to exiting the room, staff were expected to wash or sanitize immediately upon exiting the room prior to beginning another task. The facility policy titled Enhanced Barrier Precautions (EBP), revised 03/26/2025, documented EBP was employed when performing high-contact resident care activities such as a) dressing b) bathing/showering c) transferring d) providing hygiene e) changing linens f) changing briefs or assisting with toileting A facility policy titled Transmission-Based Precautions (Isolation), updated 03/2025, documented contact isolation precautions: personnel having contact with infected resident should wear gloves and a gown, prior to leaving the resident's room, gown and gloves are removed and hand hygiene performed. A facility policy titled Handwashing/Hand Hygiene updated August 2025, documented personnel were to follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene was to be after removing gloves. 2) Multiple residents reported itchy skin and expressed concerns about a possible skin condition affecting multiple residents at the facility. A review of the facility's infection control surveillance process revealed a document titled Line Listings for Infections by Resident. Between the dates of 12/09/2025 and 12/13/2025 a total of 18 residents was identified with skin infections, rash and deemed health care associated infection (HAI). The identified pathogen/organism was infectious dermatitis. Eight additional residents were identified as infectious dermatitis exposure. For a total of 26 residents affected. The document identified the 26 residents were placed in contact isolation and provided treatment including antibiotics. A color-coded map of the facility dated December 2025, revealed hallways 100, 200, 300, 500, 600, and 700 were affected with either residents with infectious dermatitis color coded in blue, or infectious dermatitis exposure color coded in green. On 12/18/2025 at 11:29 AM, during a joint interview, the Infection Preventionist (IP) and the Director of Nursing (DON), stated a skin condition was identified on 12/09/2025 which consisted of a red rash, itchiness on different areas of the body including the abdomen, arms, and peri area. Some rashes were lightly raised; some were flushed to the skin. Shingles were ruled out. The Medical Director, the Physician's Assistant, and the Wound Doctor rounded on the residents. The Medical Director diagnosed it as infectious dermatitis. Residents were placed on contact precautions and physicians treated the exposed residents as preventative measures. The IP and DON reported one staff member was affected and displayed the same symptoms. The staff member was sent to a local urgent care clinic and was treated for symptoms of scabies. The IP and DON clarified that the staff member was not diagnosed with scabies, instead was treated for the symptoms of scabies. The IP and DON reported all but four resident's skin condition had resolved. The four remaining residents were improving and would be off isolation in the next few days, and no new cases had been identified since 12/13/2025. The IP and DON explained difficulties of obtaining a diagnosis of scabies including having to take residents to a dermatologist. Although scabies were not officially diagnosed, measures were taken and residents were treated as suspicion of scabies to protect residents. The IP was familiar with outbreak reporting requirements and was aware of the process to report a facility outbreak. The IP acknowledged the skin condition and more than 1 case constituted a reportable outbreak. The IP reported the Medical Director said to report it as infectious dermatitis. The facility reached out to the state infection prevention contact via email to request guidance, no response was received, no follow-up attempt to contact the state IP was made, and the facility did not report the outbreak. On 12/18/2025 at 2:03 PM, the Medical Director (MD), reported initially two new cases of itchy skin were reported to the MD, then a roommate in the same area. The MD explained scabies were difficult to diagnose, skin scraping would have needed to be done to diagnose. The MD diagnosed residents with infectious dermatitis, and all affected residents were treated as if it was suspicion of scabies for resident safety. The MD reported facility was to report outbreaks and once there was suspicion of cases a report to the state should have been made. The Medical Director stated the facility did not have a confirmed infection of scabies, but it was treated as the same, which was reportable to the state. A facility policy titled Outbreak of Communicable Diseases, updated 04/22/2023, documented the facility identified and managed infectious outbreaks in accordance with standards of practice as established by federal, state, and local guidance. An outbreak of most communicable diseases was defined as one the following, one case of an infection that was highly communicable, trends that are ten percent or more above the historical rate of infection for the Center, or occurrence of three or more cases of the same infection over a specified period of time and in a defined area. The executive Director/Designee was responsible for telephoning a report to the health department.

Based on observation, interview, record review, and document review, the facility failed to 1) monitor and report a decline in function for 1 of 19 residents (Resident 65) and 2) identify and report a resident's increase in pain related to worsening contractures for 1 of 19 unsampled residents (Resident 14). The deficient practice placed the residents at risk for diminished function and potentially an impact on the physical, mental and psychosocial well-being of the residents. Findings include: Resident 14 (R14) R14 was admitted on [DATE] with diagnoses including contractures of the right hand and foot. According to the Minimum Data Set, R14 scored a 03 which indicated the resident was not able to make needs well known. R14 was also diagnosed with aphasia (inability to articulate spoken words). Review of R14's care plan revised on 03/26/2024, identified: - Resident had limited physical mobility related to cerebral vascular accident (stroke). Goals included: - The resident will remain free of complications related to immobility, including contractures and skin breakdown. Interventions included the following: - Carrot orthotic (hand splint) in right hand, document refusal - Physical therapy, Occupational Therapy referrals as needed. - Right hand splint - Soft passive range of motion (ROM) to right hand. - Place rolled towel if unable to tolerate carrot orthotic (Hand splint) - Provide gentle range of motion as tolerated with daily care. - Physical therapy (PT), Occupational therapy (OT) referral as needed. -Review of the Physician's orders showed the following: - Place orthotic in right hand during the day, check placement, if resident refuses orthotic, perform passive range of motion (ROM). - Soft ROM to right hand in the morning. Place rolled towel in between fingers and palm if orthotic is refused. - Monitor placement of right-hand splint by therapy and check skin for breakdown upon removal of splint. - Monitor skin to right hand contracture for skin breakdown every shift. Review of the Treatment Administration Record (TAR) reviewed from 10/01/2024 to 10/10/2024, ordered soft passive ROM to right hand daily in AM. Place rolled towel between fingers and palm if carrot is refused. The TAR showed R14 wore the orthotic four of those days and refused the orthotic six of those days Review of the progress notes dated 10/01/2024, documented R14 had severe expressive aphasia which made it difficult for the resident to verbalize needs and got easily frustrated. On 10/08/24 at 1:54 PM, R14 was observed with right hand contracture with no splinting. On 10/10/24 at 8:11 AM, therapy director stated R14 was discharged from OT 10/4/24. The director stated it was recommended for the resident to wear the carrot splint to prevent worsening contractures, as well as to protect the resident's skin. On 10/10/24 at 8:33 AM, observation of R14's right hand showed no splinting with fingers curled up in a tight fist. On 10/10/24 at 4:19 PM, observation of R14's right hand showed no splinting with fingers curled up in a tight fist. Hand splint was seen sitting on the bedside tray table. On 10/11/24 at 8:25 AM, observation of R14's right hand showed no splinting with fingers curled up in a tight fist. Hand splint was seen sitting on the bedside tray table. On 10/11/24 at 9:57 AM, observation of R14's right hand showed no splinting with fingers curled up in a tight fist. Hand splint was seen sitting on the bedside tray table. On 10/11/24 at 10:03 AM, the CNA who was taking care of R14 stated the restorative CNA was responsible for placing the orthotic. CNA stated the restorative CNA was pulled to work on the floor but would have more knowledge about the resident's required use of the orthotic. On 10/11/24 at 10:05 AM, restorative nursing assistant (RNA) was called to the resident's bedside. The RNA stated R14 was to have the carrot orthotic on but had a tendency to pull it out. The RNA was asked to place the carrot orthotic on the resident's right hand that was tightly contracted into a fist. The RNA lifted the resident's right-hand fingers to place the orthotic and the resident screamed out loud with facial grimacing and started to cry. R14 could not articulate the pain due to aphasia. After two attempts with the resident crying out in pain, the orthotic was successfully placed. R14 was then asked to remove the orthotic, tried several times and could not. The CNA stated R14 was having increasing pain related to wearing the orthotic. CNA stated they were required to report resident changes to the DON. On 10/11/24 at 10:15 AM, the resident care manager (RCM) stated R14's hand contracture pain was known, and the resident was getting pain medications. RCM stated the resident had the orthotic for a long time. When asked further questions about what was being done for the resident's pain, the RCM stated to speak to the DON who oversaw the restorative program On 10/11/24 at 10:41 AM, RNA stated there was no resident documentation specific to the resident refusing to wear the orthotic. RNA stated the nurses would document in detail the resident's pain regarding the orthotic and pain associated with wearing the orthotic. RNA stated R14 was never on a restorative program but had orders to wear the orthotic. On 10/11/24 at 12:49 PM, the Director of Nursing (DON) stated the CNAs should have reported the resident's issues regarding increasing pain associated with contractures. On 10/10/2024 at 1:50 PM, a change of condition policy was requested, DON stated a policy was not available. Resident 65 (R65) R65 was admitted on [DATE] with diagnoses including general weakness. Minimum Data Set (MDS) report indicated R65 scored a 15 on the Brief Interview for Mental Status (BIMS). This score indicated R65 was able to make needs well known. On 10/08/2024 at 10:12 AM, R65 was observed to have bilateral hand contractures. R65 was able to pick up a cup to drink but could not hold a toothbrush to brush upper and lower teeth. R65 stated the care staff provided no assistance with oral care and had not brushed teeth in a long time. R65 showed upper and lower teeth that were brown in color with heavy yellowish, brownish build up. On 10/09/2024 at 11:26 AM, R65 was observed to have bilateral hand contractures. R65 stated not having received oral care that day, was not able to hold toothbrush and was not getting any assistance with oral care On 10/09/2024 at 11:30 AM, the Certified Nursing Assistant (CNA) who took care of R65 was called to the resident's bedside. Upon observation, the CNA noted the resident's teeth were brownish, with heavy yellowish build up. The CNA stated based on the observation of R65's upper and lower teeth, the resident was not getting adequate oral hygiene. The CNA stated R65 was usually set up with a toothbrush, with toothpaste and was able to brush teeth without staff assistance. The CNA stated R65 was not set up to brush teeth that day and when asked why, CNA stated I don't know. The CNA was then asked to set up the resident to brush teeth as usual. The CNA placed toothpaste on the toothbrush and handed it to R65. After a few attempts, the CNA observed and stated R65 could not effectively hold the toothbrush and the resident brushed teeth by keeping the toothbrush still while turning their head side to side, instead of using circular hand motions to brush. On 10/09/2024 at 11:44 AM, the Resident Care Manager (RCM) was called to the resident's bedside. Upon observation, RCM noted the resident was not able to hold the toothbrush well enough and agreed R65 used their head by turning it side to side to brush. RCM stated the resident used to be able to brush their own teeth without assistance but was no longer able due to worsening hand contractures. The RCM did not state R65's worsening hand contractures and decline in function were documented or reported for further intervention. On 10/09/2024 at 11:50 PM, the Director of Nursing (DON) confirmed R65 was not on a restorative program and was not referred to Occupational Therapy (OT). On 10/10/2024 at 7:39 AM, the therapy director who oversaw the OT department, stated based on the documentation, the resident was discharged from OT on 02/02/2024. The director stated it was recommended for R65 to be enrolled into a restorative program for upper extremity functional maintenance. The director stated at the time of discharge from OT, R65 was able to grip and propel the wheelchair wheels using their hands independently. On 10/10/2024 at 1:00 PM, an Occupational Therapist was called to the resident's bedside and an assessment was done by OT, to determine R65's ability to brush teeth independently with set up. The therapist made the same observation and stated based on the resident's current ability and prior level of function, R65 would need to be back on OT due to a decline related to worsening hand contractures. During the assessment, the resident complained of pain in fingers while holding the toothbrush. After the assessment, visual observation of the resident's teeth showed no thick yellowish buildup and teeth no longer had the brownish color that was observed before. OT progress notes and evaluations documented R65 was assessed by OT on 10/30/2023. The note showed R65 had bilateral wrist contractures but did not have any functional limitations due to the contractures. The note also showed assistive hand devices (orthotics) were not needed upon discharge from OT. The note also showed R65's hand function was modified independent (able to perform tasks using an assistive device or with assistance). Following the bedside assessment made on 10/10/2024, an OT note documented R65 had developed functional limitations due to contractures. The note showed hand splints were recommended but R65 was not able to tolerate. Manual hand treatments were then recommended to eventually allow for the use of the hand splints. Review of R65's care plan revised on 05/10/2024, identified: - R65 had an activities of daily living (ADL) self-care deficit related limited mobility and range of motion (ROM). Goals included: -The resident will improve current level of function in upper and lower extremities. Resident will be able to perform tasks independently. - Staff to anticipate needs Interventions included the following: - Encourage the resident to participate to the fullest extent possible with each interaction. - Physical Therapy (PT) /OT evaluation and treatment as per MD orders. The care plan lacked documentation to show goals and interventions for R65 decline in function related to worsening hand contractures. Review of the restorative, nursing progress notes from 06/2024 to 10/01/2024, documented R65 was on a restorative program from 02/2024 to 06/13/2024. Review of the progress notes from 06/13/2024 to 10/01/2024 lacked documentation to show R65's decline in hand function was reported to OT and R65's physician. Review of the daily oral hygiene flowsheets reviewed from 06/2024 to 10/2024, documented various days where R65 was setup, independent or partial/moderate assist for oral care. Review of the undated policy titled Activities of Daily Living, documented: - If the resident appears to be declining or needing more assistance, the nurse should be notified. Review of a facility document titled Change in condition, described when clinical staff should report to the medical provider. The document read: - Any symptom, sign or apparent discomfort that is: * A marked change in relation to usual symptom and signs or * Unrelieved by measures already prescribed The document further defined: - Non- immediate notification * New or worsening symptoms that do not meet above criteria On 10/10/2024 at 1:50 PM, requested Change of Condition policy and DON stated did not have one. On 10/11/2024 at 2:31 PM, the DON stated the RNA's should have reported the resident's decline in function in brushing teeth. DON stated education was needed for the CNA's/RNA's to report any change in condition such as decline in function related to worsening contractures. DON stated the RCM should have also communicated the resident's worsening hand contractures.

Based on interviews and document review, the facility failed to ensure food concerns raised by the resident group were acted on, followed through and facility's actions (if any) were communicated back to the resident group. The deficient practice had the potential to have negative psycho-social outcomes to the residents. Findings include: On 10/09/2024 in the morning, Resident 51 (R51) was alert, oriented, and answered questions appropriately. R51 revealed being the President of the Resident Council. R51 explained the resident council meets on a regular basis every month to discuss any concerns to be brought to the attention of the facility staff. Discussions during the resident council were recorded by a staff member during the meeting. The Resident Council President indicated on the following dates the resident council discussed concerns regarding meals with no follow up or response from the facility: - 06/06/2024 - 07/11/2024 - 08/2024 - 09/06/2024 - 10/04/2024 On 10/09/2024 at 11:03 AM, the Resident Council President indicated food has been discussed on a regular basis, but the facility has not provided a plan. Five out of five residents involved in the resident council agreed this remark was true. On 10/09/2024 in the morning, Resident 8 (R8) indicated the grievances were not taken seriously and at times the former Executive Director had confronted the resident regarding the resident's concerns. The resident explained the former Executive Director was invalidating the resident's feelings. On 10/09/24 at 11:06 AM, the Resident Council President indicated the former Social Worker was the grievance official and left in August and there was really no grievance official and therefore grievances were not being addressed. On 10/09/24 at 11:27 AM, five residents indicated old business was not discussed in the subsequent meetings and facility action was not communicated to the resident group. The Resident Council President and R8 filed a grievance on food and received no response. If the grievance form documented a resolution to the resident's satisfaction, the resident verbalized disagreement this discussion took place. There was no one who got back to the residents and the documentation (if any) never took place. A grievance form dated 08/18/2024, documented Resident 55 (R55) filed a formal complaint regarding cold food, watery soup, food issue cannot get fixed because no one wants to help. The grievance form documented a kitchen staff member acted by in-servicing kitchen staff regarding food temperatures and palatability. The resident and kitchen manager signed the grievance on 08/18/2024. Page 2 of the grievance form documented, Resolution of Grievance must be completed within 2 days of grievance receipt. The document indicated the grievance was resolved due to staff being in-serviced and the resident was notified of the resolution on 08/20/2024. A grievance form dated 08/18/2024, documented Resident 51 (R51) filed a formal complaint regarding food not getting any better, late and cold and looks disgusting. The grievance form documented a kitchen staff member acted by in-servicing kitchen staff regarding food temperatures and palatability. The resident and kitchen manager signed the grievance on 08/18/2024. Page 2 of the grievance form documented Resolution of Grievance indicated the grievance was resolved due to staff being in-serviced and the resident was notified of the resolution on 08/20/2024. The document failed to include a physical signature from Residents 55 and 51 who were both alert and able to provide written signatures. On 10/09/24 at 2:09 PM, Residents 55 and 51reviewed their respective grievances dated 08/18/2024 and acknowledged the complaints regarding food were indeed verbalized by the residents. The residents reviewed the documents which revealed actions taken by the facility included in-services provided to kitchen staff regarding food temperatures and palatability which rendered the grievances resolved with results communicated and provided to the residents on 08/20/2024 was false. The residents indicated no one came to speak with the residents and the facility dismissed the grievances as resolved without resident approval. On 10/09/24 at 2:18 PM, the Activities Director, Director of Nursing, and Executive Director were made aware of the allegations from the residents. The three staff members agreed the facility policy for response to resident council concerns was not followed. The Executive Director acknowledged the Social Worker left employment in August and there was no full-time replacement as of the date of the investigation, the role was being filled between a part-time Social Worker and the Director of Nursing. The facility policy titled Resident Council (revised January 2017) documented residents have the right to gather and discuss thoughts, ideas, or issues related to the care and treatment. Concerns brought forth by the Council were resolved via the Center's grievance policy. Council members were encouraged to make suggestions and offer constructive criticism to staff advisors and or the Executive Director. The Center communicates a response and or decision to the Resident Council by the next meeting.

Based on observation, interview, and document review, the facility failed to ensure 1) kitchen staff were wearing appropriate facial coverings during food preparation and 2) molded strawberries were not being prepped for service. The deficient practice placed residents at risk for food related illnesses from ingesting contaminated food. Findings include: On 10/08/24 at 8:45 AM, the kitchen director and a cook were observed to have full beards and were not wearing beard nets during the initial tour of the kitchen. The kitchen director stated they should have been wearing beard nets. On 10/10/24 at 11:27 AM, observed another cook preparing multiple fruit salad plates, used strawberries that came from a container with a heavily molded strawberry. The cook was made aware of the molded strawberry, picked it up and attempted to throw it out of the container. The kitchen director who was watching the encounter told the cook to throw out the entire container of strawberries stating that the other strawberries were also contaminated. The kitchen director stated the staff member will need to be educated on infection control and food contamination. The kitchen director stated the staff member should have been more aware of the contaminated fruit. Facility policy tilted, Staff Attire, revised on 10/2023 stated the following: - All staff member will have hair off shoulders, confined to a hair net or cap with facial hair properly restrained. Facility policy for food and nutritional services titled, Personal Hygiene Standards, revised on 06/2021 documented: - employees with beards, should wear beard guards

Based on observation, interview, record review, and document review, the facility failed to develop a baseline care plan for a resident who was admitted with a condom catheter for 1 of 19 sampled residents (Resident 140). The deficient practice had the potential to place the resident at risk for not receiving appropriate care related to the condom catheter which included perineal care and site monitoring. Findings include: Resident 140 (R140) R140 was admitted on [DATE], with diagnoses including chronic kidney disease stage 3 and atherosclerotic vascular disease. On 10/08/2024 at 10:43 AM, R140 laid flat in bed with eyes closed, a family member was at bedside. The family member indicated the resident was in the hospital for eight days following a fall at home and R140 had significantly declined in cognitive and physical abilities since the hospitalization . The family member explained R140 had only half a kidney left, was incontinent and had a urinary catheter which was placed in the hospital. The family member searched for the urinary catheter by lifting the blanket and looking underneath the bed and expressed confusion as to why R140 no longer had a urinary catheter, maybe they removed it. An admission note dated 01/04/2024, revealed R140 was incontinent of urine and had a condom catheter in place. The medical record lacked documented evidence a baseline care plan was developed to include interventions in managing R140's condom catheter such as site monitoring, and perineal care. On 10/09/2024 at 10:49 AM, the Certified Nursing Assistant (CNA) assigned to R140 indicated being in the room when the Resident Care Manager (RCM) removed R140's condom catheter the day before. The medical record lacked documented reason and circumstance on why R140's condom catheter was removed. On 10/09/2024 at 11:53 AM, the admitting Registered Nurse (RN) recounted R140 had a condom catheter when admitted on the evening of 10/04/2024. The RN indicated being a new nurse and was working with agency nurses at the time of R140's admission so the nurse did not know and could not ask anyone regarding how to proceed with R140's catheter. The RN acknowledged forgetting to mention R140's condom catheter to the day nurse during shift report. On 10/09/2024 at 12:00 PM, the RCM confirmed being assigned to R140 when the resident's condom catheter was starting to come off on the morning of 10/08/2024. The RCM obtained a removal order from the provider who was making rounds, but the RCM acknowledged forgetting to document the incident in R140's medical record. The RCM reviewed R140's medical record and confirmed care interventions related to the resident's condom catheter was not included in the resident's baseline care plan but should have been because it counted as an immediate care need. The RCM indicated care interventions included perineal care, replacing with correct size catheter and site assessment specifically the skin on which the condom catheter was attached. On 10/09/2024 at 3:39 PM, the Director of Nursing (DON) indicated the admitting nurse was responsible for entering care orders for R140's condom catheter which included monitoring site and urine, perineal care, and replacing with correct catheter size. The DON indicated the condom catheter was considered an immediate care need and should be included in the resident's baseline care plan. According to the DON, the condom catheter was not an invasive device and did not require a justification for continued use or an order to remove but appropriate care must be carried out for as long as the condom catheter was present. The Baseline Care Plan policy updated April 2024, documented the baseline care plan was developed within 48 hours of admission and included information regarding care and services sufficient to promote safe delivery of care. The baseline care plan consisted of physician orders, initial goals and goals triggered by the admission nursing evaluation.

Based on interview, record review and document review, the facility failed to ensure 1) a physician's PRN order for an anti-anxiety medication had a stop date for 1 of 19 sampled residents (Resident 70) and 2) a gradual dose reduction was attempted for a psychotropic medication for 2 of 19 sampled residents (Residents 23 and 70). The deficient practice placed the residents at risk for receiving unnecessary medications. Findings include: The facility policy titled Psychotropic Drugs, documented psychotropic drugs were any drug which affects brain activities associated with mental processes and behavior. Residents taking psychotropic medications would undergo a gradual dose reduction unless contraindicated. As needed psychotropic medications were limited to 14 days unless a rationale was provided by the practitioner and documented in the medical record. Resident 70 (R70) R70 was admitted on [DATE] and readmitted on [DATE] with diagnoses including mood disorder and anxiety disorder. 1) An active physician order dated 03/31/2024 documented to give Alprazolam 0.5 mg by mouth every 6 hours as needed for restlessness. The medical record lacked documented evidence of an end date for as needed psychotropic medication. R70 had psychotropic consent form signed and active physician orders for the following additional psychotropic medications: - Olanzapine 10 milligram (mg) - Buspirone 15 mg - Depakote 500 mg - Zoloft 50 mg Resident 23 (R23) 2) R23 was admitted on [DATE] and readmitted on [DATE] with diagnoses including psychotic disorder with hallucinations and major depressive disorder. A physician order dated 07/23/2024 documented to give Sertraline 25 mg once daily for depression. A physician order dated 09/19/2024 documented to give Quetiapine 25 mg two times a day for antipsychotic. A physician order dated 08/05/2024 documented to give Buspirone 15 mg three times a day for anxiety. The medical record lacked documented evidence R70 and R23 received a gradual dose reduction or rationale of why it was not performed for multiple psychotropic medications. On 10/10/2024 at 1:40 PM, the Consultant Pharmacist verbalized completing medication regimen review at least monthly for all residents of the facility. R70 or R23 did not have any recent recommendations from the Pharmacist. The Consultant Pharmacist confirmed all psychotropic medications with an as needed use should have a 14-day end date unless it was documented by the physician to continue. The Consultant Pharmacist indicated all psychotropic medications must undergo a gradual dose reduction conducted by a physician or physician extender. On 10/10/2024 at 1:49 PM, the Director of Nursing (DON) explained the primary physician at the facility did not feel comfortable completing the gradual dose reduction for psychotropic medications and the facility had recently switched to having the psychiatric physician or practitioner completing the gradual dose reduction. The DON indicated some residents have not received the gradual dose reduction due to switching to a different provider. The DON acknowledged and confirmed R70 had an active order for a psychotropic medication which was to be used as needed and there was no end date. The DON explained the resident had been in and out of the facility and it was an oversight during the latest admission.

Based on observation, interview, and document review, the facility failed to ensure outdated and expired vaccine vials were discarded in accordance with the facility's policy. Specifically, two opened vials of Influenza vaccine (formula Year ,d+[DATE]) were found inside the medication refrigerator. The deficient practice placed residents at risk for receiving outdated and expired Influenza vaccine during flu season ,d+[DATE]. Findings include: On [DATE] at 9:12 AM, an inspection of the medication refrigerator in the 100-Hall storage room revealed two vials of Flucelvax Quadrivalent Influenza vaccine (formula ,d+[DATE]), Lot number AU313OB. Both vials were opened with contents, not labeled with open date, and had an expiration date of [DATE]. On [DATE] at 9:15 AM, the Resident Care Manager (RCM) confirmed the observation and explained RCMs were responsible for checking the medication rooms on a monthly basis to inspect for expired patient care medications and items. The RCM could not speak to why the Influenza vials for last year's flu season were still inside the medication refrigerator. On [DATE] at 9:22 AM, the Director of Nursing (DON) explained the RCMs, or any nurse were expected to inspect the medication rooms monthly to check for expired and outdated items for disposal. The DON was inside the medication room and confirmed the two vials of Influenza vaccine were opened with contents, undated, outdated and expired. The DON indicated last year's flu season ended in the beginning of [DATE] and there should have been no reason the vaccines had not been discarded until now. The DON verbalized the finding reflected routine inspections were not being done as expected. The Medication Storage policy dated 2007, documented outdated and discontinued medications are to be immediately removed from stock and disposed of according to procedures for medication disposal. Medication storage conditions were monitored on a regular basis as a random quality assurance check. When problems were identified, recommendations for corrective action must be taken.

Based on observation, interview, record review and document review, the facility failed to ensure 1) a hospice physician's order to get resident out of bed daily was followed and, 2) hospice aides reported a loosened pressure ulcer dressing to the facility nurse for 1 of 19 sampled residents (Resident 15). The deficient practice had the potential to negatively impact quality of life by depriving the resident of environmental stimulation and social interaction and placed the resident at risk for wound complications. Findings include: Resident 15 (R15) R15 was admitted on [DATE], with diagnoses including multiple sclerosis and hospice status. A hospice physician's order dated 07/12/2024, documented to get R15 out of bed to chair daily. The medical director for the skilled nursing facility (SNF) wrote an order dated 07/12/2024, to get R15 out of bed to chair daily during day shift. The quarterly minimum data set (MDS) dated [DATE], revealed R15 had a brief interview of mental status (BIMS) of 15 (intact cognition), was totally dependent on staff for activities of daily living (ADLs) and bed to chair transfers. R15 did not have rejection of care behaviors, was able to understand and could sometimes make self-understood using verbal and non-verbal expression. On 10/08/2024 at 10:50 AM, R15 laid flat in bed facing ceiling with eyes opened. R15 was able to respond to simple questions by moving head side to side to mean No and up and down to mean yes. R15's television (TV) was off, there was no music or any form of stimulation, and the window blinds were shut. R15 indicated being in hospice care and hospice staff came a couple of times a week to see the resident. On 10/09/2024 at 10:00 AM, R15 laid flat in bed facing ceiling with eyes opened. Television was off, no music or other stimulation, window blinds were shut. On 10/10/24 at 9:36 AM, R15 laid flat in bed facing ceiling with eyes opened. Television was off, no music or other stimulation, window blinds were shut. R15 nodded head from side to side when asked whether hospice staff had come to visit the resident since 10/08/2024. On 10/10/2024 at 10:56 AM, two hospice aides were outside R15's room. The aides indicated they came three times a week to provide R15 a shower, linen change, and other activities of daily living (ADLs) such as incontinence and oral care. One hospice aide indicated R15 had a stage three pressure ulcer with dressing coming off and the aide planned to communicate the loose dressing with R15's primary nurse. The two hospice aides indicated not being aware there was a physician's order to get R15 out of bed and it would not be a good time to get R15 out of bed now because the resident was watching favorite soap opera on TV. On 10/10/2024 at 11:05 AM, the aides entered R15's room with surveyor. R15 appeared clean, head of bed elevated approximately 30 to 40 degrees with TV on a soap channel. R15 had a big smile on face and nodded when asked if this was one of R15's favorite shows. The hospice aides were present when R15 indicated being interested in getting out of bed and going outside for fresh air, had not been offered by any staff to get out of bed and R15 would not refuse to get out of bed if offered. The hospice aides left R15's room verbalizing had another resident to see in the facility. On 10/10/2024 at 11:15 AM, the Registered Nurse (RN) indicated being assigned to R15 at least twice a week and was familiar with the resident. The RN indicated being aware R15 had an order to get out bed daily and assumed Certified Nursing Assistants (CNAs) had been offering the service to R15. The RN indicated expecting if R15 refused, the CNAs were to re-offer the service and report refusals to the RN who would speak with the resident, discuss, identify and address the resident's reason for refusal. The RN reviewed R15's medical record which revealed R15 was last gotten out of bed on 10/03/2024 during the flu shot clinic. The RN confirmed there was no documentation of offers, re-offers or resident refusals regarding the out of bed order for R15. The RN indicated the hospice aides had left for the day but did not communicate with the RN regarding R15's stage three wound dressing coming off. On 10/10/2024 at 11:28 AM, the CNA assigned to R15 indicated being assigned to R15 at least twice a week and was familiar with the resident. The CNA indicated not being aware there was an out of bed order for R15, so the CNA had not been offering the service when assigned to the resident. On 10/10/2024 at 12:02 PM, the hospice RN indicated the physician's order to get R15 out of bed was written by the hospice physician per the resident's own request in July 2024. The RN indicated not being aware staff were not offering the service to R15 on a daily basis per physician's order notwithstanding the resident had the right to refuse this service. On 10/10/2024 at 12:12 PM, the Director of Nursing (DON) reviewed R15's medical record and confirmed the last time R15 was gotten out of bed was on 10/03/2024, which was the date of the facility's flu clinic. The DON indicated R15 was bedfast, required total care and would benefit from getting out of bed for repositioning and social interaction among other things. The DON indicated expecting staff to offer R15 the service in accordance with the physician's order and to re-offer the service should the resident refuse the first attempt. According to the DON, resident refusals were to be communicated with the nurse who was expected to discuss, identify and address reasons for refusal and document the same in the resident's medical record. The DON indicated R15 currently had a stage three pressure ulcer for which the care was commonly shared between the hospice provider and facility staff. The Hospice Provision of Care policy updated September 2017, documented the hospice and facility communicated and agreed upon a coordinated plan of care based on an evaluation of the individual needs of the resident. Medications and services were provided as indicated by the agreement for coordination of services. The Hospice agreement dated 11/01/2020, documented hospice may use the facility's nursing personnel to assist in the administration of prescribed therapies.

Based on interview, record review and document review, the facility failed to ensure a resident with a full code status was provided basic life support (BLS) after having been found unresponsive for 1 of 9 sampled residents (Resident 1). The deficient practice deprived the resident of life-saving measures, specifically cardiopulmonary resuscitation (CPR) which may have potentially increased the resident's chances of recovery and survival. Findings include: Resident 1 (R1) R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including Alzheimer's disease with late onset, nutritional deficiency, and urinary tract infection (UTI). A provider order for life-sustaining treatment (POLST) dated [DATE], revealed R1 was evaluated by the physician assistant to have decisional capacity and the resident elected to be a full code (attempt CPR in the event of cardiopulmonary arrest). A quarterly social services assessment dated [DATE], revealed R1 expressed wanting to remain full code. A nursing progress note dated [DATE], revealed a Certified Nursing Assistant (CNA) reported to the nurse R1 had expired. The Licensed Practical Nurse (LPN) assessed the resident to be unresponsive, no respirations noted with absent pulse. The LPN notified the Director of Nursing Services (DNS) and Sheriff. A nursing progress note dated [DATE], documented the DNS notified the physician R1 had expired, and the Sheriff was at the building to pronounce death. The medical record lacked documented evidence the nurse or CNA initiated CPR, called a Code Blue (response to a resident who was found without vital signs), or called 911 (emergency services) when the resident was found unresponsive without pulse or respirations. A facility report submitted to the state agency on [DATE], revealed an allegation of neglect was verified by the facility concerning an LPN who did not initiate CPR on a full code resident who was found unresponsive with no pulse or respirations on [DATE]. Based on the report, the LPN reasoned not performing CPR on the resident because, the resident really looked dead. The LPN was suspended during the investigation with intention to terminate. On [DATE], two attempts to contact the LPN of concern (LPN 1) for a telephone interview were made at 8:19 AM and 12:20 PM, both attempts were unsuccessful. On [DATE] at 9:19 AM, an LPN (LPN 2) indicated working alongside LPN 1 on [DATE] with LPN 1 being assigned to the 600-Hall and LPN 2 assigned to the 500-Hall. LPN 2 explained a Code Blue was typically announced using the overhead paging system, but according to LPN 2 there was no Code Blue incident during the shift on [DATE]. LPN 2 recalled conversing with LPN 1 at the nurse's station towards end of shift when LPN 1 casually verbalized R1 had expired. On [DATE] at 1:05 PM, an attempt was made to contact the CNA assigned to R1 on [DATE]. The attempt was unsuccessful. The DNS indicated the CNA was on vacation leave and may not be reachable. On [DATE] at 1:48 PM, another CNA recounted not being assigned to R1 on [DATE] but assisted with R1's bed bath earlier in the morning. The CNA indicated not being familiar with R1 but reported a light pink vaginal discharge in R1's brief to LPN 1 who told the CNA the finding was not off baseline since R1 had an active UTI with hematuria (blood in urine). On [DATE] at 10:42 AM, the physician assistant (PA) recalled receiving a phone call from LPN 1 on [DATE] regarding abnormal findings in the resident's renal ultrasound collected on [DATE]. According to the PA, R1's renal ultrasound indicated blood was found in the resident's bladder, but the PA did not order a hospital transfer since the resident's vital signs were stable and no significant vaginal bleeding was reported. The PA indicated not being familiar with R1 and deferred to the resident's attending physician. On [DATE] at 2: 28 PM, the attending physician indicated being familiar with R1's medical condition. The physician described R1 as advanced in age with multiple co-morbidities and had been on a steady versus rapid decline. The physician indicated laboratory and other diagnostic tests were being ordered, reviewed, and addressed with abnormal findings being treated as soon as they were identified. The physician indicated R1 was recently treated with intravenous (IV) fluids for dehydration and had been on oral antibiotics for UTI. The physician explained a renal/bladder ultrasound was ordered on [DATE] due to R1's hematuria (blood in urine) and results of which became available on [DATE]. According to the physician, R1's cystitis would have been treated with bladder irrigation but unfortunately the resident expired within hours of the diagnostic report being received. The physician verbalized staff reports of the resident being restless, refusing to eat and drink and vaginal discharge were not new symptoms and could be treated at the facility-level without ruling out a need for a hospital transfer in the event of a rapid decline or need for higher level of care. The physician indicated many factors may have played a role in the resident's demise which included an infection at old age, high potassium, and high blood urea nitrogen (BUN) due to poor renal function and volume depletion. On [DATE] at 2:35 PM, the physician verbalized R1 had a full code status and the LPN who walked into the resident's room and found R1 unresponsive without pulse or respirations should have initiated CPR because it was unknown how long the resident had been unresponsive. On [DATE] at 8:56 AM, the Executive Director (ED) and the DNS confirmed there were no providers, or anyone authorized to pronounce death in the building on [DATE]. The ED indicated the LPN should have confirmed R1's code status, initiated CPR, called a code blue which would have prompted other staff members to get involved by calling paramedics, getting the crash cart, and continuing with chest compressions until paramedics took over the scene. The ED verbalized the LPN had been employed at the facility since [DATE], was considered a seasoned nurse and was expected to have carried out the facility's code blue process properly prior to contacting the DNS. On [DATE] at 9:01 AM, the DNS recounted receiving a phone call from the LPN 1 in the late afternoon of [DATE]. The DNS recalled assuming the LPN had already done all the right steps prior to the phone call, namely, 1) confirming the resident's code status, 2) initiating CPR, 3) calling a code blue, 4) continued with chest compressions until paramedics arrived. The DNS acknowledged telling the LPN to call the Sheriff to pronounce death because the DNS assumed all proper steps had already been taken by LPN 1. On [DATE] at 11:27 AM, the CNA who was assigned to R1 on [DATE] indicated being familiar with the resident. According to the CNA, the resident had an Oxygen saturation reading in the 70's (normal range: 95% or higher) but after repositioning the nasal cannula, the reading went up to 96%. The CNA confirmed the resident had been eating and drinking less and had started to refuse care, but the decline had been a steady decline over a period of months. The CNA indicated it was difficult to determine whether the resident's demise was due to a delay or failure in care versus a natural occurrence because the resident's vital signs were normal on [DATE]. The CNA indicated reporting the resident's desaturation, and increased restlessness to the LPN but the CNA verbalized being uncertain if the LPN checked on the resident without the CNA knowing, since the CNA had become very busy throughout the shift. The facility policy on CPR required all nurses to be current with BLS. Review of LPN 1's training record revealed a current CPR card issued [DATE] and a renew date of ,d+[DATE]. The CPR policy updated [DATE], documented CPR would be initiated for residents who elected to have CPR initiated in their POLST. The Code Blue policy dated [DATE], documented when a resident was found without vital signs the first responder would call a code blue. Once the code status was established, CPR would be initiated for residents who elected CPR in their POLST. A code team leader is established, and necessary duties assigned. The emergency cart would be promptly brought to the scene, Oxygen management promptly initiated, and CPR would be continued until emergency personnel arrived and took over. Completion of the post event evaluation and code event minutes was done by a licensed nurse or support team during the code blue event. Following the [DATE] event related to failure to initiate CPR on a full code resident, the facility had taken the following corrective actions: - the LPN of concern was terminated on [DATE] - the board of nursing had provided written acknowledgment of the facility's complaint regarding the LPN's neglect on [DATE] - the inter-disciplinary team (IDT) reviewed the POLST of all residents - the nursing report sheets were updated to include residents' code status - in-services regarding change of condition, code status, CPR and code blue were provided to staff - the DNS audited basic life support (BLS) certifications of all direct care staff - a mock code drill was conducted on [DATE] with intent to conduct drills quarterly once per shift - the IDT discussed the incident and corrective actions post-incident at a quality assurance and improvement (QAPI) meeting on [DATE] Complaint #NV00070703 FRI #NV00070695

Based on observation, interview and document review, the facility failed to ensure 1) the emergency crash cart was free of expired supplies, 2) staff were trained on the suction equipment, oral airway device and automated external defibrillator (AED) and 3) mock code drills were conducted quarterly once per shift in accordance with facility policy. The deficient practice placed residents' safety at risk as a result of poor-quality response to an emergency such as aspiration, choking and cardiopulmonary arrest. Emergency Crash Cart On [DATE] at 9:23 AM, a Registered Nurse (RN) and the Resident Care Manager (RCM) were present for an inspection of the emergency crash cart located in the 500-Hall and 600-Hall nurse's station. The crash cart checklist for [DATE] and [DATE] reflected the emergency crash cart was checked daily with no missed entries. The RN and RCM indicated the night shift staff were assigned check the contents of the crash cart. The RCM confirmed the following observations: - six Amsino brand yankauer devices - expired [DATE] - three Medline brand yankauer devices - expired [DATE] - one bottle sterile water expired [DATE] - one compressor nebulizer - vendor maintenance due [DATE] - one suction swab expired [DATE] On [DATE] at 10:09 AM, the staff development coordinator (SDC) confirmed checking central supply and indicated there were no unexpired yankauer devices (an oral suctioning tool made of firm plastic) in the facility. Suction Device On [DATE] at 9:33 AM, the RCM confirmed there were no yankauer devices in the crash cart which were not expired. RCM indicated not being certain how the night shift staff checked the suction equipment and confirmed there was no practice yankauer attached to the suction device. The RCM indicated night shift staff were expected to physically plug in the suction equipment, turn the device on and test suction. The RCM was asked to demonstrate use of suction equipment. On [DATE] at 9:39 AM, the RCM connected the connector tubing to the gauge and the other end to the canister. The RCM and RN verbalized not knowing what the normal reading was for a well-functioning suction equipment. The RN and RCM indicated although they were not certain what the normal suction reading was, the RN and RCM verbalized suction strength should not be too weak nor too strong. The RN and RCM stated if the suction was too weak it would be ineffective in suctioning and if the suction strength was too strong it may hurt the patient. On [DATE] at 9:46 AM, the RN indicated according to the manufacturer's website, the suction device should have a reading between 10 millimeters (mm) of Mercury (Hg) (mmHg) to 15 mmHg. On [DATE] in the afternoon, the Executive Director (ED) confirmed staff had not been trained in the use of the suction equipment. AED device On [DATE] at 11:03 AM, two RNs were at the 300-Hall nurse's station where a yellow AED device was mounted on the wall box covered with a glass door. The RNs indicated the AED device was new and was delivered to the facility about a week prior. According to the RNs, the facility did not have an AED device prior to the arrival of this AED device. The RNs indicated receiving one-on-one informal training from the SDC for use of the AED device but did not receive any formal training and the RNs indicated being uncomfortable using the device. On [DATE] at 12:04 PM, the SDC indicated had received the AED device as a grant on [DATE] and nurses had not received formal training for the AED device. The SDC explained the function of the AED was to determine if there was cardiac activity and would prompt the user to deliver a shock if needed to re-establish cardiac activity. The SDC indicated the facility utilized American Red Cross or American Heart Association as the BLS standard of practice, but the SDC was uncertain if the AED was a required component. The facility's training for CPR was limited to compressions until paramedics arrived. On [DATE] in the afternoon, the Executive Director (ED) confirmed staff had not been trained in the use of the AED device. Oral Airway device On [DATE] at 9:51 AM, the crash cart had eight sizes of oral pharyngeal airway (OPA) devices distinguished from one another by color. The Registered Nurse (RN) indicated not being certain how to measure the OPA device appropriately to fit an individual. The RN indicated not being certain if the flange (flattened tip) was placed at the center of the mouth or the tip of the lip during measurement. The RN indicated knowing the correct size OPA must be used on patients because if the OPA was too big it could obstruct the airway and if it was too small it would not be able to keep the airway open. The RN could not recall when the last training was regarding OPA devices. On [DATE] at 10:00 AM, the SDC indicated being uncertain on how to properly measure an OPA device to an individual. Mock Code Drills On [DATE] at 10:17 AM, an LPN indicated being employed for nine years but had not attended a mock code drill. The Mock Code Blue Drill policy dated [DATE], documented drills were held a minimum of once a quarter on each shift. Review of the facility's mock code drills lacked documented evidence a mock code drill was conducted in the first and fourth quarter of 2023. On [DATE] at 12:58 PM, the SDC confirmed the facility did not conduct mock code drills for the first quarter (Jan-March) 2023 and fourth quarter of 2023 (October-December). On [DATE] at 11:21 AM, the Executive Director (ED) and the Director of Nursing Services (DNS) indicated the facility assessment last reviewed on [DATE], documented resident care needs would include a proper response to emergencies such as cardiopulmonary arrests. According to the DNS, the facility assessment drove competency requirements. The DNS provided the general orientation checklist for new and existing hires which enumerated training topics which were refreshed annually and as needed. The General Orientation Checklist did not include orientation with the crash cart, operation and maintenance of the suction equipment and AED, use of an oral airway device or Code blue. On [DATE] at 11:28 AM, the DNS verbalized prior to the incident on [DATE] newly hired nurses and existing nurses were not trained on 1) checking all components of the crash cart, 2) oral pharyngeal airway use, 3) use and equipment check for suction machine and 4) use of AED device and 5) Code blue. The DNS acknowledged the above-mentioned topics should have been included in the training requirements for new and existing hires based on the needs of the resident care population of the facility.

Based on interviews, record review, and document review, the facility failed to complete or document the status of the orthopedic follow-up consultation for fractured bilateral feet for 1 of 4 sampled residents (Resident 2). This deficient practice had the potential to delay the necessary medical intervention and exacerbate the resident's pain and complications. Findings include: Resident 2 (R2) R2 was admitted on [DATE], with diagnoses including a closed fracture, a nondisplaced fracture of the lateral malleolus of the right fibula, a fifth metatarsal bone, a left foot, and weakness. A Physician order dated 01/30/2023, documented to follow up with an orthopedic surgeon in one week. A Care Plan dated 02/02/2023, documented R2 had an alteration in musculoskeletal status related to a fracture of bilateral feet. The interventions included the following for weight bearing status and to see physician orders. A Physician Progress Note dated 02/09/2023, documented the Chief Complaint / Nature of the Presenting Problem: skilled visit for a for a bilateral lateral malleolar fracture. After a fall, R2 presented with a bilateral malleolus fracture and a left second through 5th metatarsal base fracture. R2's fractures were non-operative, and was to follow up as an outpatient. On 04/04/2024 at 1:35 PM, a Registered Nurse (RN) assigned to R2 explained the process for outside consultations required a physician order. The RN indicated the staff member who received the order would relay it to the appointment scheduler. Staff could access the established schedule via the electronic calendar. The RN indicated the resident Care Manager who received the order at the time no longer worked at the facility. The RN verified R2's orthopedic appointment had not been scheduled or canceled in both the calendar and the progress notes. The facility Outpatient Consult Calendar from 01/30/2023 to 02/10/2023, lacked documented evidence R2's orthopedic consult had been scheduled. On 04/04/2024 at 1:53 PM, the Business Office Generalist (BOG) explained an outpatient consultation required an order. The BOG indicated responsibilities included scheduling appointments for residents, liaising with the physician's office for outpatient consultations, and organizing transportation for residents to and from appointments. The BOG explained if an appointment had been finalized, the date, time, and instructions would be placed in the electronic calendar. The BOG confirmed there was no indication R2's orthopedic appointment was set up, completed, or canceled. On 04/04/2024 at 2:15 PM, the Director of Rehabilitation Services (DORS) emphasized the significance of orthopedic consultation for therapy. Therapists sought updates on the R2's weight bearing status and healing progress to enhance the resident's journey towards returning home. The DORS explained therapists could perform strengthening exercises, but optimal treatment hinged on the R2's weight-bearing status. The DORS further indicated the necessity of an orthopedic consultation, given the bipedal nature of human locomotion, to enhance R2's quality of life. On 04/04/2024 at 2:58 PM, the attending doctor could not recall the care of R2 for it had been more than a year. The attending physician indicated the staff were expected to follow and carry out R2's orthopedic consult. On 04/04/2024 at 3:15 PM, the Director of Nursing (DON) indicated if the schedule was finalized or had changes, nursing would be informed. The DON confirmed there was no documented evidence R2's orthopedic appointment was completed or canceled. On 04/09/2024 at 9:42 AM, the Divisional Director of Clinical Operations (DDCO) indicated there was not a specific policy for following physician's order but this was an expectation per [NAME] standard of practice and nursing overall. The DDCO provided the RN job description, which documented how RNs obtained and administered prescribed medications and treatments in accordance with approved nursing techniques and documented the same according to the facility's standards of practice. The DDCO indicated a physician's order for a consult or referral would fall under treatment services. Complaint #NV00068006

Based on observation, interview, and policy review, the facility failed to ensure a resident's room was in good repair and free of debris on the floor for one of four residents (Resident (R)41) rooms observed for a clean, homelike environment out of a sample of 18 residents. Findings include: Review of facility policy titled, Homelike Environment, updated July 2015 revealed, Policy Statement: Resident rooms are personalized and organized in a matter that promotes independence through a homelike environment. Procedure: . c. Room is free of hazards. During an observation and interview on 11/27/2023 at 2:11 PM, R41's room revealed scrapes on the wall behind the bed with pieces of the wall laying in a pile on the floor. The baseboard was not attached to the wall. R41 was asked about the wall damage, R41 was not aware of the wall damage. During an interview on 11/30/2023 at 2:33 PM, the Maintenance Director was asked how often rounds were made to look for needed repairs in the rooms. The Maintenance Director would go into the rooms and look for life safety issues but, did not use a form to identify when the room checks were done. The Maintenance Director was shown the wall behind the bed. The Maintenance Director stated, These beds usually will tear up the walls, but I did not realize it was this bad. The Maintenance Director was last in the room on 06/15/2023 conducting the Annual GFCI Receptacle Testing. During an interview on 11/30/2023 at 3:35 PM, the Administrator said after looking at the pictures of R41's wall, I guess that is not very homelike. The Administrator added, It turns out one of the nurses who worked Monday saw the wall but failed to put it on the maintenance log. The Administrator was asked what the expectation was when staff noticed damage. The Administrator stated, I expect staff to report items like that and they be repaired.

Based on observation, interview, record review, and review of the RAI [Resident Assessment Instrument] Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for three out of 18 sampled residents (Residents (R)21, R28, and R64). Findings include: During an interview on 11/30/2023 at 3:11 PM, the Administrator stated the facility did not have any policies regarding MDS assessments. The Administrator stated the facility used the RAI Manual for guidance on completion of MDS assessments. Review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 October 2023 revealed, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b) (1) (xviii), (g) and (h) require that (1) the assessment accurately reflects the resident's status . the assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. 1. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R21 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis. Review of the admission MDS with an assessment reference date (ARD) of 05/26/2023 in the EMR under the MDS tab revealed R21 was not identified under Dental as having any abnormalities such as obvious or likely cavity or broken natural teeth or inflamed or bleeding gums or loose natural teeth. During observations on 11/27/2023 at 2:30 PM R21 was observed with broken and decayed teeth. During an interview on 11/29/2023 at 1:33 PM, the Resident Care Manager (RCM) stated R21's teeth were in poor condition; they were broken and rotted. During an interview on 11/30/2023 at 11:32 AM, the Hospice Case Manager (Registered Nurse) stated R21's teeth were in poor condition (broken teeth with decay), and the Hospice Case Manager had noticed a problem of R21'a gums bleeding when the teeth were brushed, and the resident's teeth had been in this condition since admission to hospice on 05/12/2023. During an interview on 11/30/2023 at 9:47 AM, Certified Nursing Assistant (CNA)4 said R21's gums bled when brushing the resident's teeth. During an interview on 11/30/2023 at 11:54 AM, the MDS Coordinator verified no abnormalities were identified on R21's Admission MDS for Dental. The MDS Coordinator reviewed the admission nursing assessment and the whole medical record when completing the MDS assessments. The MDS Coordinator stated if the medical record did not document a problem with R21's dental condition, it was not coded that there was a problem on the MDS. The MDS Coordinator did not consistently go and look at a new resident prior to completing the initial assessment. The MDS Coordinator required documentation of a concern in the lookback period such as broken or decay teeth or the MDS Coordinator could not code it on the MDS even if it was observed. During an interview on 11/30/2023 at 4:18 PM, the Director of Nursing (DON) expected nursing staff to document broken decayed teeth on the MDS if they were present and expected nurses to look at the resident in person as part of the MDS process. a. Review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 October 2023 revealed, Identify unstageable pressure ulcers - 1. Visualization of the wound bed is necessary for accurate staging. 2. If after careful cleansing of the pressure ulcer/injury, a pressure ulcer's/injury's anatomical tissues are obscured such that the extent of soft tissue damage cannot be observed or palpated, the pressure ulcer/injury is considered unstageable . If the pressure ulcer/injury was unstageable on admission/entry or reentry, then becomes numerically stageable later, is should be considered as present on admission at the stage at which it first becomes numerically stageable . Definition Stage 3 Pressure Ulcer - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling . Definition - Deep Tissue Injury - Purple or maroon area of discolored intact skin due to damage of underlying soft tissue . Review of the quarterly MDS with an ARD of 11/18/2023 in the EMR under the MDS tab revealed R21 had two unstageable pressure injuries presenting as deep tissue injury. R21 was not coded with any stageable pressure ulcers. Review of the Nurse Practitioner's Skin/Wound Note dated 11/27/2023 in the EMR under the Progress Notes tab listed an ongoing narrative regarding the condition of R21's pressure injuries including, . 11/27 - Treatment provided by clinician, right buttocks wound increased in size since last visit; 2.5 cm [centimeter] [length] x [by] 3 cm [width] x 1.5 cm [depth] . left buttocks wound with same measurements of; 1cm x 1cm x 1.5 cm, . 11/20 - Left buttocks, 1cm x 1cm x 1.5 cm ., right buttocks 2.5 cm x 2.5cm by 1cm . 11/13 - Treatment provided by clinician, wound measurements on right buttocks 2.5 cm x 3 cm x 1.5 cm ., left buttocks wound 1cm x1cm x 1cm depth . 10/30 - Treatment Provided by clinician . right wound approximately 2.5 cm x 2cm x 0.5 cm. Left wound 1 cm x 1 cm x 1 cm with tunneling/undermining noted . During an observation on 11/29/2023 at 11:00 AM, Registered Nurse (RN)1 completed wound care of the left buttock and right buttock pressure injuries. During an interview on 11/29/2023 at 1:41 PM, the RCM stated R21 had two pressure ulcers, each with depth and would therefore be stage 3 pressure ulcers. During an interview on 11/30/2023 at 12:07 PM, the MDS Coordinator stated skin was intact with a deep tissue injury (DTI). The MDS Coordinator had not observed R21's pressure injuries but the pressure injuries should be coded as stage three and not DTI after the condition of the wounds was described. The MDS Coordinator utilized the coding established from the wound care team when completing the MDS. During an interview on 11/30/2023 at 3:19 PM, the Medical Director stated if a pressure injury was open and there was depth to the wound, the staging should be changed from a DTI to the appropriate stage. During an interview on 11/30/2023 at 4:30 PM, the DON stated the coding on the MDS indicating R21's pressure injuries were DTIs, was not correct. The DON stated the nurses thought pressure injuries would be considered healing DTIs. The DON stated when a DTI opened, it should be staged accordingly. 2. Review of the Profile tab located in the EMR revealed an Admission Record for R28 with an admitted [DATE]. Review of the Orders tab located in the EMR revealed an order dated 04/19/2023, for Oxygen 2 liters per minute [lpm], delivery: (cannula) to keeps sats greater than 90% (O2) as needed. Review of the quarterly MDS located in the EMR under the MDS tab with an ARD of 10/21/2023, revealed under respiratory services, oxygen was not marked while a resident in the facility. During an interview on 11/30/2023 at 5:25 PM, the MDS Coordinator revealed the Nursing Notes did not indicate R28 was on oxygen, however it should have been marked if the resident used oxygen. 3. Review of R64's discharge return anticipated MDS with an ARD of 11/30/2022 showed a facility admitted [DATE]. Review of R64's Care Plan from the EMR Care Plan tab showed R64 was readmitted on [DATE] with medical diagnoses that included paroxysmal atrial fibrillation, acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF). During an observation on 11/27/2023 at 12:19 PM, it was noted R64 had on a nasal cannula attached to an oxygen concentrator set at two liters per minute (lpm). During an interview and observation on 11/28/2023 at 2:53 PM, R64 continued to have oxygen at two lpm via nasal cannula. On 11/30/2023 at 11:05 AM, during an interview and observation, R64 stated when R64 was having some abdominal issues it was hard to breathe so the resident requested oxygen. The oxygen was noted to be at two lpm via nasal cannula. Review of R64's MDS assessments from the EMR MDS tab showed a significant change of status assessment, with an ARD of 12/12/2022 was not coded for oxygen use. Review of R64's Progress Notes from the EMR Progress Notes tab, showed on 12/12/2022 at 3:05 PM the patient [R64] was currently receiving oxygen. Review of R64's Significant Change of Status Assessment with an ARD of 01/21/2023 was not coded for oxygen use. A review of R64's Progress Notes showed on 01/20/2023 at 3:18 PM stated R64 was currently receiving oxygen. Review of R64's quarterly MDS with an ARD 06/30/2023 was not coded for oxygen use. Review of R64's Progress Notes showed on 06/28/2023 at 12:33 PM that R64 was currently receiving oxygen via nasal cannula. Review of R64's Care Plan from the EMR Care Plan tab showed a focus of The resident has oxygen therapy r/t [related to] Ineffective gas exchange PRN [as needed] initiated on 10/26/2022. During an interview on 11/30/2023 at 5:40 PM, the MDS Coordinator confirmed the three MDS assessments were not coded for oxygen. During an interview on 11/30/2023 at 4:40 PM, the DON stated an expectation the resident be coded for oxygen on the MDS assessments if there were orders for daily use. Review of the October 2019 Resident Assessment Instrument (RAI) manual, page O-3 showed: O0100C, Oxygen therapy Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaric oxygen for wound therapy in this item. This item may be coded if the resident places or removes his/her own oxygen mask, cannula. 18750 28154

Based on observation, interview, record review and review of the RAI [Resident Assessment Instrument] Manual, the facility failed to develop comprehensive care plans for two of 18 sampled residents (Residents (R)21 and R62). Specifically, R21 did not have a care plan to address R21's deteriorated dental condition, and R62 did not have a care plan to address oxygen use. This had the potential for the residents to have unmet care needs. Findings include: During an interview on 11/30/2023 at 3:11 PM, the Administrator stated the facility did not have a policy for care planning and used the RAI Manual for guidance. Review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 October 2023 read in pertinent part, The RAI helps nursing home staff gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan . the care plan becomes each resident's unique path toward achieving or maintain their highest practical level of well-being. 1. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R21 was admitted to the facility on [DATE] with a diagnosis of multiple sclerosis. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/2023 in the EMR under the MDS tab revealed R21 was unimpaired in cognition with a Brief Interview for Mental Status score (BIMS) of 15 out of 15 (score of 15 indicates intact cognition). R21 was dependent on one person for all activities of daily living (ADLs) including personal hygiene. Review of the Care Plan dated 11/24/2023 in the EMR under the Care Plan tab revealed under the problem of, Establish the baseline plan of care with a goal of, will have ADL /functional ability needs met. There were no approaches on the care plan related to the provision of oral care/hygiene. During observations on 11/27/2023 at 2:30 PM, R21 had food, food particles and/or white residue between the teeth and gums in addition to broken, decayed teeth. During an interview on 11/29/2023 at 1:33 PM, the Resident Care Manager (RCM) stated R21's teeth were in poor condition; they were broken and rotted. The RCM stated the condition of R21's teeth should be care planned along with the need to provide oral care after meals. The RCM reviewed R21's Care Plan and verified that neither the compromised condition of R21's mouth nor the need for staff to provide oral care were addressed on the care plan. During an interview on 11/30/2023 at 11:32 AM, the Hospice Case Manager (Registered Nurse) stated R21's teeth were in poor condition (broken teeth with decay). The Hospice Case Manager stated a soft toothbrush with Peridontex toothpaste should be used to brush teeth. 2. Review of the Profile tab located in the EMR revealed an Admission Record for R62 that indicated an original admission into the facility on [DATE], with diagnoses of atherosclerotic heart disease, adult failure to thrive, and anxiety. Review of R62's the Orders tab located in the EMR revealed an order dated 04/19/2023 for Oxygen 2 liters per minute [lpm], delivery: (cannula) to keeps sats greater than 90% (O2) as needed. Review of R62's Care Plan tab located in the EMR revealed there was no Care Plan for R62's oxygen indicating no interventions or goals for the use of the oxygen. During an interview on 11/30/2023 at 5:25 PM, the Director of Nursing (DON) indicated the resident should have a care plan for oxygen therapy. 18750

Based on observation, interview, review of CNA [Certified Nursing Assistant] Competency Oral Hygiene document, and record review, the facility failed to ensure one out of three dependent residents reviewed for activities of daily living (Resident (R)21), out of a sample of 18 residents, was provided with adequate oral hygiene. Findings include: During an interview on 11/30/2023 at 3:11 PM, the Administrator stated the facility did not have a policy for oral care/oral hygiene; however, provided an undated document titled, CNA [certified nursing assistant] Competency Oral Hygiene document. The CNA Oral Hygiene document directed staff to, Collect items (i.e., toothbrush, toothpaste, mouthwash, water cup, basin, etc.) . apply gloves, then brush teeth in a circular motion, brushing gums, teeth, tongue (as able). Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R21 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, dysphagia (swallowing disorder), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/18/2023 in EMR under the MDS tab revealed R21 was unimpaired in cognition with a Brief Interview for Mental Status score (BIMS) of 15 out of 15. R21 was dependent on one person for all activities of daily living (ADLs) including personal hygiene. During an observation on 11/27/2023 at 2:30 PM, R21 was lying in bed. R21 had accumulated white residue along the gum line and between the teeth. R21 was able to answer yes and no questions by shaking his head up and down or side to side. R21 lacked movement of the arms/hands and could not perform ADLs including brushing teeth. R21 indicated staff provided oral care. During an observation on 11/29/2023 at 7:40 AM, R21 was lying in bed. Food residue was observed in between the teeth and gums. During an interview on 11/29/2023 at 9:09 AM, a Certified Nursing Assistant (CNA)5 stated R21 was totally dependent on staff for oral care. The CNA stated R21 communicated to staff by shaking their head yes or no. CNA5 stated R21's gums bled when oral care was provided. CNA5 stated hospice staff came to the facility and provided oral care to R21 on Mondays, Wednesdays, and Fridays; facility CNAs did not provide oral care on these days. During an interview on 11/29/2023 at 1:33 PM, the Resident Care Manager (RCM) stated R21's teeth were in poor condition and verified they were broken and decayed. The RCM stated oral care should be provided after each meal. During an observation on 11/30/2023 at 9:34 AM, R21 had black food particles observed on their teeth. R21 indicated staff did not brush their teeth after breakfast. During an interview on 11/30/2023 at 9:47 AM, CNA4 had provided care to R21 that morning after breakfast. The CNA used a toothette (soft foam sponge on a stick designed for swabbing the mouth of individuals to provide moisture and remove some particles) and had been unable to remove all the food from R21's mouth that morning after breakfast. CNA4 did not use a toothbrush because R21's gums bled when the teeth were brushed with a toothbrush. During an interview on 11/30/2023 at 11:32 AM, the Hospice Registered Nurse (RN) stated R21's teeth were in poor condition (broken teeth with decay) and had been in that condition when the resident was admitted on to hospice services on 05/12/2023. The Hospice RN stated the hospice aides brushed R21's teeth with a soft bristle toothbrush and used a special toothpaste, Peridontex, to help with R21's bleeding gums. The RCM stated a toothbrush with Peridontex toothpaste (specialized toothpaste designed to prevent bleeding gums) should be used for providing oral care. During an interview on 11/30/2023 at 4:18 PM, the Director of Nursing (DON) expected staff to provide oral care two or three times a day to R21, ideally after meals, which involved brushing R21's teeth. R21's care plan did not address the provision of oral care.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure two of two sampled residents (Resident (R)21 and R28) who were bedridden were offered activities of their interest. This deficient practice had the potential for the residents to not have their psychosocial well-being met. Findings include: Review of the facility's policy manual titled Activity Program, dated July 2015 revealed, Policy Statement: The Center provides an ongoing program of activities designed to meet the interests as well as a physical, mental, and psychosocial well-being of each resident. Policy Statement: The Activity Staff offers specialized activities to meet specific resident needs. The Activity Department's primary purpose is to provide a varied activity program addressing each resident's needs. 1. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed R21 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis. Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/26/2023 in the electronic medical record (EMR) under the MDS tab revealed R21 was unimpaired in cognition with a Brief Interview for Mental Status score (BIMS) of 15 out of 15. R21 was totally dependent for all activities of daily living (ADLs) and was admitted on hospice services. Under Interview for Activity Preferences, it was very important for R21 to listen to music the resident liked, be around animals such as pets, to do things with groups of people, to do favorite activities, and to go outside when the weather was good. Review of the Care Plan dated 05/24/2023 in the EMR under the Care Plan tab revealed a problem of [R21] has little or no activity involvement r/t [related to] hospice diagnosis. Has end-stage MS [multiple sclerosis]. The goal was, [R21] will express satisfaction non-verbally by smiling or making facial expressions during 1-1 sensory visits provided by activity staff at at least 3x a week. Interventions in full were, -Monitor/document the impact of medical problems on activity level. Resident is on hospice. -The resident is able to: smile and communicate through body language. -The resident's preferred activities are watching TV and indicated enjoys pets. Review of the Initial Activity Evaluation dated 05/24/2023 in the EMR under the Evaluation tab revealed R21's preference for activity participation included activities in the resident's room and 1:1 (one to one) visits. R21's favorite activities were animals/pets, current events/trivia, movies, music, radio, reading/library, and television. The activity plan was, [R21] will receive 1-1 sensory supportive visits from activity staff. Hospice staff involved as well . [R21] is bed-bound, on hospice and unable to speak. No known family to respond to questions. Review of the quarterly Activity Progress Note dated 08/15/2023 in the EMR under the Progress Notes tab revealed the summary of the resident's participation and response for the quarter was, [R21] is bed bound and on hospice for palliative care. R21 is non-verbal but able to nod head during social visits. Prefers to sleep and has the TV on throughout the day . Watches TV in room. No new interests . Little to no involvement in activities, Need 1-1 visits for sensory engagement. Review of the quarterly Activity Progress Note dated 11/17/2023 in the EMR under the Progress Notes tab revealed, Prefers to sleep, watch TV and talk with activity staff throughout the day. Watches TV in room . Receiving 1:1 visits for sensory engagement . During an interview on 11/29/2023 at 9:46 AM, the Social Services Director (SSD) stated R21 mouthed words and could answer yes or no questions; there was a communication card in the room staff could also use for communication. During observations on 11/27/2023 at 2:30 PM; 11/28/2023 at 11:49 AM; on 11/29/2023 at 7:40 AM, 11:14 AM, 12:54 PM 2:14 PM; and 11/30/2023 at 9:34 AM, R21 was lying in bed with the TV on to the same channel being watched by the roommate. During an interview on 11/27/2023 at 2:30 PM, R21 indicated the resident had no family or other visitors from the community coming to visit. R21 did not get out of bed, preferred not to get out of bed, and had no voluntary movement of their body except for the neck and head. R21 was unable to read due to not being able hold a book. R21 watched TV but would like to do other activities besides TV. R21 liked music but did not have a radio; music had not been provided in the room as an option versus watching TV. During an interview on 11/29/2023 at 7:40 AM with R21. R21 would enjoy books on tape, but this had not been offered. R21 stated the activity staff did not visit. During an interview on 11/30/2023 at 9:34 AM with R21. R21 was watching the news on the TV. R21 would like to listen to books on tape and would like to have pet visits. R21 verified R21 did not receive visits from activity staff. During an interview on 11/30/2023 at 9:47 AM, Certified Nursing Assistant (CNA)4 was asked about in room activities for R21. CNA4 stated R21 watched TV and watched whatever the roommate was watching; the roommate operated the remote control and selected what to watch. R21's TV was turned to the same programs. During an interview on 11/29/2023 at 9:09 AM, CNA5 stated R21 was asked about in room activities for R21. CNA5 stated R21 liked to watch TV and to chit chat. CNA5 stated R21 liked soap operas and game shows. CNA5 verified R21 and the roommate both had their TVs on all day and their TVs were turned to the same stations. During an interview on 11/29/2023 at 1:00 PM, the Activity Director (AD) stated R21 should be receiving 1:1 visits three to four times a week. The AD stated 1:1 visits should be care planned and participation in 1:1 visits was tracked. The AD stated R21 liked music. The Activity Director stated when they visited the resident, the Activity Director played songs on their cell phone or I Pad. The AD verified R21 did not otherwise listen to music in their room. The AD talked to R21 about cars, clothing, food, traveling, etc. The AD stated R21 liked animals/pets, but the Activity Director did not have anyone to provide pet visits. The AD stated R21 would like headphones to watch/listen to what they wanted on TV if the roommate was watching something the resident did not want to watch. The AD verified both R21 and roommate had their TVs on all the time. Review of Activities participation records from 09/01/2023 - 11/29/2023 provided by the facility showed one 1:1 visit documented on 11/17/2023; there were no other 1:1 visits documented in this three-month period. There were 55 entries of independent TV watching. There was an entry of people watching on 10/03/2023 and of a snack and special event on 09/22/2023. During a follow up interview on 11/30/2023 at 10:52 AM, the AD stated the 1:1 visits were not documented, and stated there was no reason why. The AD stated the Activity Aide was responsible for completing and documenting 1:1 visits, although the AD had completed some 1:1 visits with R21. The AD stated nursing staff had been developing the activity care plans. The AD stated the care plan focused on hospice and had nothing to do with activities. During an interview on 11/30/2023 at 11:14 AM, the Activity Assistant stated R21 liked visits and watching TV. The Activity Assistant visited with R21, and R21 nodded to yes and no questions. The Activity Assistant forgot to document the 1:1 visits. The Activity Assistant stated R21 liked music but did not listen to it independently in the resident's room. The Activity Assistant had not tried books on tape. The Activity Assistant stated R21 did not communicate which shows the resident liked to watch on TV. 2. Review of R28's EMR revealed an undated Admission Record located under the Profile tab with an admitted [DATE]. Review of R28's significant change MDS located under the MDS tab with an ARD of 07/20/2023 revealed a BIMS score of seven out of 15 indicating severe cognitive impairment. Preferences for Customary Routine and Activities revealed listening to music, being around animals, and religious services and practices were very important. Doing favorite activities and getting fresh air were somewhat important. Review of R28's Care Plan located under the Care Plan tab revealed a Care Plan with a revised date of 09/28/2023 indicating a goal of maintaining involvement in cognitive stimulation with participation. Interventions included, Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interest and preferences; Adapted as needed, Compatible with individual needs and abilities; Establish and record the resident's prior level of activity involvement and interests; Invite the resident to scheduled activities. Review of the Activities Log provided by the facility revealed during the month of September 2023 there were 20 days recorded that the resident was watching TV and nine days with a family member visit. Review of the Activities Log provided by the facility revealed during the month of October 2023 there were 14 days recorded that the resident was watching TV and had a family member visit. Review of the Activities Log provided by the facility revealed during the month of November 2023 there were 16 days recorded that the resident was watching TV and nine days with a family member visit. During an interview on 11/27/2023 at 10:37 AM, Family Member (FM)1 was asked about activities for R28. FM1 stated, I have not seen them do anything with R28. R28 used to make jewelry and loved to play BINGO. It would be nice to see the resident participate. Observations of R28 made on 11/28/2023 at 10:09 AM, at 3:14 PM, on 11/29/2023 at 7:19 AM, on 11/30/2023 at 9:08 AM and at 2:10 PM revealed R28 was lying in bed, the TV was not on, and the curtains were drawn on the windows. There was no documented evidence R28 received one on one activities or was encouraged to participate in activities. During an interview on 11/30/2023 at 10:43 AM, The Activity Director was asked about doing in-room activities or one on one. The Activity Director was doing the in-room activities and tried to see the resident three times a week. The Activity Director was working with the resident to come out of the resident's room. The Activity Director confirmed there was no documentation to show R28 was provided one on one activities in the resident's room. The Activity Director further confirmed there was no documented evidence R28 refused to come out of their room for activities. 15406

Based on interview and clinical record review, the facility did not ensure hydration for 1 of 4 sampled residents (Resident #1). Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was admitted to an Acute Care Facility 02/15/2014, and was diagnosed with [REDACTED]. The documentation from that facility indicated the dehydration was "probably secondary to her age and debility and dementia... (Resident #1) is probably not taking in enough oral intake. Does not seem to be any metabolic disorder. Patient was hydrated with normal saline at 125 cc (cubic centimeters) per hour." On 01/14/2014, the Registered Dietician assessed Resident #1's fluid needs as 1350-1620 milliliters daily. On 01/14/2014, Resident #1's physician ordered Calorie Dense Med Pass (a fluid), 60 milliliters, to be given by mouth, three times per day. Resident #1's "Medication Administration Record" indicated that in February 2014, the Med Pass was at times refused (see Meal Monitor Flowsheet documentation below). On 01/12/2014, Resident #1's Care Plan for "Nutrition Hydration Status" was developed. The identified problem was Altered Nutrition Hydration Status related to cognitive issues, functional decline, and poor skin integrity. The identified interventions included diet according to order, offer liquids between meals, monitor meals and if intake is equal to or less than 50%, offer a substitute or supplement, provide assistance with set up, cueing, and assistance of the meal, refer to Registered Dietician if appropriate, and observe for signs and symptoms of dehydration for example dry mouth, cracked lips, dry skin, and decreased urinary output. Resident #1's "Meal Monitor Flowsheet" recorded the meal percentages, cubic centimeters (cc) consumed, and the Medication Administration Record [REDACTED] Fluids consumed were recorded for the fourteen days that immediately preceded the resident's transfer to the Acute Care Facility and diagnosed with [REDACTED]. 02/01/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 360 cc, 60 cc Med Pass (a fluid) given at 8:00 AM and 12:00 PM, refused at 8:00 PM. 02/02/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 360 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, refused at 8:00 PM. 02/03/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 460 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and 8:00 PM. 02/04/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 440 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and 8:00 PM. 02/05/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 930 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and 8:00 PM. 02/06/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 620 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and 8:00 PM. 02/07/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 280 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and refused at 8:00 PM. 02/08/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 380 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and refused at 8:00 PM. 02/09/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 780 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and refused at 8:00 PM. 02/10/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 780 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and 8:00 PM. 02/11/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 700 cc, 60 cc Med Pass given at 8:00 AM. 02/12/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 240 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and 8:00 PM. 02/13/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 500 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM. 02/14/2014: Total cc documented for the day from the Meal Monitor Flowsheet: 530 cc, 60 cc Med Pass given at 8:00 AM and 12:00 PM, and 8:00 PM. No documentation the Registered Dietitian was notified Resident #1 was not meeting the assessed fluid requirements could be located. On 04/02/2014, the Registered Dietician was interviewed. The Dietitian stated besides the Meal Monitor Flowsheet and Med Pass found on the Medication Administration Record, [REDACTED]. Resident #1's clinical record at the Skilled Nursing Facility documented during dinner on 02/15/2014, Resident #1 was "seen to be leaning towards right side (with) right-sided facial drooping. Call placed to (name of Physician). (Due to) possible stroke symptoms...". The Physician was notified and Resident #1 was sent to the Emergency Department. The clinical record from the Acute Care Facility Resident #1 to which the resident was transferred was reviewed. The record indicated Resident #1 was transferred via ambulance at 8:00 PM on 02/15/2014. In the Emergency Department, Resident #1 was diagnosed with [REDACTED]. The record stated on 02/15/2014 at 8:00 PM, Resident #1's blood pressure was 225/127 mmHg (millimeters of mercury), indicating the resident's blood pressure was severely elevated. An Electrocardiogram (EKG) showed the resident had a rapid heart rate with premature [MEDICAL CONDITION] complexes. The resident was admitted to the Medical-Surgical Unit for further IV hydration on 02/15/2014 at 11:30 PM. Resident #1 was discharged back to the Skilled Nursing Facility on 02/16/2014.

Based on interview, clinical record review and document review, the facility failed to ensure each resident had the necessary supervision and devices to prevent accidents for three of five sampled residents (Resident #1, # 3 and # 4). The facility failed to ensure their written policies for fall management, alert charting and neurological evaluations were followed for three of five sampled resident (Resident #1, # 3 and # 4). Findings include: The facility's policy entitled, Fall Management ( revised ,[DATE]), documented, the facility would implement a fall management plan based on the resident evaluation. #1. The nurse completes the Fall Evaluation at admission and quarterly before completing the Minimum Data Set (MDS). Residents, who were disorientated, confused or who had fallen in the past 3 months were also considered high potential for falls. Documentation entitled, Neurological Evaluation Policy dated ,[DATE], indicated in the event a resident had a fall and it was suspected or known the resident had bumped/hit their head, neurological evaluations were initiated and continued for 72 hours and the resident was placed on alert charting for 72 hours. Documentation entitled, Alert Charting Policy indicated the alert charting system was implemented when resident's experienced a change in condition. #1. The nurse was to evaluate the resident's condition when a change in condition/change from baseline was observed or reported. Examples included in part ... abnormal vital signs, skin problems, vomiting, and falls... #6. The physician and resident's authorized representative were notified. The notification was documented in the resident's clinical record... #9. The care plan was updated when alert charting was discontinued.... Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nurses note for Resident #1 dated [DATE] at 5:20 PM, documented Resident #1 was found on the floor by the side of the bed in her room. The note indicated the facility notified Hospice and family. Rendered first aid to left knuckle (skin abrasion). A Band-Aid was applied and the notes indicated the resident would be monitored. The nurses note dated [DATE] at 5:20 PM, lacked documented evidence Resident #1's vital signs were obtained, neurological checks had been initiated, or the resident's range of motion had been evaluated after the fall. The clinical record lacked documented evidence neurological checks had been done in accordance with the facility's policy after the fall at 5:20 PM. Documentation entitled Triage Communication (from the Hospice agency) documented on [DATE] hospice received a call from the facility at 5:06 PM, to report Resident #1 fell possibly from weakness or tripped over the oxygen tubing cord. The resident was not injured except a scrape on the left hand knuckle, which was cleaned and bandaged. Vitals after the fall Vitals blood pressure ,[DATE], heart rate 102, respirations 24, oxygen saturation 87% on 4 liters of oxygen and Resident #1's urine was dark. The facility indicated the resident had an upper respiratory infection. On [DATE] at 7:16 PM, the facility called hospice to report Resident #1's vitals: blood pressure was ,[DATE], heart rate 99, oxygen saturation 94% on 4 liters of oxygen. Resident #1 was feeling better after a nebulizer treatment, but tired. Xanax (anti-anxiety medication) to be given with night medications and Lasix would be withheld due to resident dehydration. The clinical record lacked documented evidence the Fall Risk Assessment had been completed after the fall [DATE] at 5:20 PM. The clinical record lacked documented evidence Resident #1's fall risk care plan had been updated after the fall on [DATE] at 5:06 PM. On [DATE] at 8:30 PM, a nurses note for Resident #1 documented "I heard resident call out and went to her room and found her kneeling by her bed. I examined her and went to get the CNA (Certified Nursing Assistant) across the hall who placed her on the commode and left her w/ (with) instructions to use the call light when finished. We placed her back in bed and an incident report and initiated vitals to be taken from the resident". The clinical record lacked documented evidence Resident #1's family, physician or Hospice agency had been notified. The nurses notes lacked documentation Resident #1 had been assessed for injury, range of motion or the resident's vital signs after the fall. The clinical record lacked documented evidence neurological checks had been initiated or done in accordance with the facility's policy after the fall on [DATE] at 8:30 PM. On [DATE] at 8:45 PM, the nurses note (a Licensed Practical Nurse) documented, "the resident's (Resident #1) daughter had called at the nurses station and asked if "I would go check on her mother's phone. I said I would and have her call me on it. When I arrived in the room the resident was half over the bed and I lifted her up and determined she was deceased by checking her carotid and peripheral pulses and her "evey" (sic) were open and pupils fixed. Her daughter called on her phone and I answered and informed her that I had bad news for her. She asked if her mother was passed and I said she had." On [DATE] at 11:45 AM, a Registered Nurse (RN) verbalized per the facility's fall protocol a resident had a Fall Risk assessment completed upon admission and after every fall and quarterly. After a fall the nurse obtained a set of vital signs, completed a neurological check, checked the resident's range of motion, and assessed the resident for injuries. The resident's physician, family and the facilities Director of Nursing (DON) were notified. The nurses notes should document the information "that's a standard we go by." The RN verbalized an unwitnessed fall would include neurological checks and vital signs the first hour every 15 minutes, then the second and third hours neurological checks every 30 minutes and then checks every 4 hours times 24 hours. The RN revealed the care plan would document the new fall interventions along with the date and location of the fall. The RN verbalized the care plan was to be updated after each fall and the Fall Risk Evaluation completed after each fall. On [DATE] at 12:20 PM, a Licensed Nurse (LN) revealed the facility's policy on falls indicated a fall risk assessment was done upon admission and after a fall. The LN indicated if a resident fell the assessment should include the resident's orientation, what happened, the resident was checked for injures, range of motion, vital signs and neurological status. The LN verbalized all assessment information went into the nurses notes. The fall risk assessment would be completed and the care plan was updated after each fall. The LN verbalized the updated care plan included date of the fall, the intervention and location of the fall. The LN revealed the neurological checks were documented on the neurological flow sheet. The LN indicated there were certain time frames to check the neurological status. On [DATE] at 1:30 PM, a LN confirmed the clinical record lacked documented evidence the neurological checks had been completed on [DATE]. On [DATE] at 2:00 PM, Licensed Nurse (LN) #2 verbalized she had been familiar with Resident #1. The resident had been ill before the falls on [DATE]. The resident was weak and was on antibiotics. LN# 2 verbalized the resident required someone to be with her when she was on the bedside commode due to her weakness. Licensed Practical Nurse (LPN) #2 revealed the resident fell because a CNA had put the resident on the bedside commode and left her alone. LN #2 indicated she had been told by LN #1 who was assigned to Resident #1, the resident had fallen earlier in the day on [DATE], and later on that day the CNA had left the resident on the bedside commode. The resident was told the resident to use the call light when she was ready to get off the commode. LN #1 told her the call light was on and asked the CNA to answer the call light. LN #1 verbalized she had entered the resident's room and the resident was on the floor. During the interview on [DATE], LN # 2 verbalized LN #1 told her she had gone into the resident's room later on and the resident was sitting up in the bed bent forward. LN #1 had spoken with the resident's family member on the telephone and told the family member "I am sorry to tell you this but she is gone." LN #2 verbalized per the facility's policy the LPN was to have called a Registered Nurse and if the resident was on Hospice to call the Hospice agency. On [DATE] at 2:10 PM, a LN revealed the policy on falls indicated the resident was assessed for range of motion, bleedings, vital signs, level of conscious, if the fall was witnessed or unwitnessed. The LN verbalized if a fall was unwitnessed neurological checks were to be done. The LN indicated the documentation should include the family and physician or Hospice were notified, the resident was to be charted on every shift times 3 days and a fall risk assessment was done after each fall. The LN verbalized the resident's care plan was to be updated with new interventions. The LN verbalized the person who left Resident #1 on the bedside commode was a Nursing Assistant in Training (NAT) at the time of the fall not a CNA. On [DATE] at 9:10 AM, a CNA verbalized Resident #1 required one person assist and if the resident was weak the resident should not be on the bedside commode alone. On [DATE] at 9:29 AM, a CNA verbalized Resident #1 required assistance with transfers and was not to be left alone on the bedside commode because she was sick and weak. On [DATE] at 10:59 AM, a CNA revealed she was a Nursing Assistant in Training when she had taken care of Resident #1 on [DATE]. The CNA verbalized Resident #1 required assistance with transfers and toileting. The CNA revealed Resident #1 had a respiratory issue and complained of not being able to breathe prior to her fall. The resident had also complained of congestion, was weak and felt tired. The CNA verbalized she had put the resident on the bedside commode and gave her the call light to call for assistance. Resident #1 had told her it was okay to leave her. The CNA verbalized she left the room to assist another resident and asked the nurse to assist Resident #1 or call when the resident was done on the bedside commode. The CNA indicated the nurse was outside the resident's room passing medications and was going into the resident's room to give medications. The CNA verbalized the nurse came into the room where she was helping the other resident and told her she needed to "take care" of Resident #1 she had fallen. The CNA verbalized Resident # 1 was on her knees and leaning over the bed. The CNA revealed she assisted Resident #1 back into the bed and "made safe in bed with oxygen on" and took the resident's vitals. The CNA indicated when she emptied the bedside commode the resident's urine was dark in color and smelled. During the interview on [DATE], the CNA verbalized at the facility the CNA's were assigned a hallway and they all were to assist the residents. The CNA verbalized she was not aware Resident #1 had fallen earlier that day. The CNA revealed she was a Nursing Assistant in Training (NAT) at the facility when Resident #1 had the fall. The CNA revealed as a NAT she was not to be alone with residents and a CNA should have been with her. The CNA verbalized per the facility's policy the CNA's were not to leave a resident alone on the commode when the resident felt ill or were sick. The CNA revealed the facility's policy was a NAT was not to be alone with a resident. The CNA verbalized she had just received her CNA certification on Sunday. On [DATE] at 1:25 PM, a LN confirmed the clinical record lacked documented evidence neurological assessments had been completed on [DATE] after Resident #1's fall. On [DATE] at 12:10 PM, LN #1 stated she was familiar with Resident #1. LN #1 verbalized on [DATE] Resident #1 was ill, the resident had an upper respiratory infection or pneumonia. The LPN verbalized she had brought the resident in tea from home because she liked it and she knew the resident was dehydrated. LN #1 indicated she knew this because of the resident's skin turgor, the resident was emaciated looking and it had been told to her in shift report. LN #1 indicated she was not at the facility when the resident fell on [DATE] at 5:20 PM, but she was on the unit when the resident fell on [DATE] at 8:30 PM. LN #1 verbalized the documentation in the clinical record it was most accurate and a description of what had happened that night. LN #1 verbalized she did work with a NAT on [DATE] on the shift. LN #1 indicated per the facility's policy a NAT was supposed to be accompanied by a CNA and a NAT could not be alone with a resident. LN #1 indicated she did not know that at the time. Resident #3 Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE], the admission orders [REDACTED]. The clinical record contained a care plan dated [DATE], for Resident #3 was at risk for injury/falls related to recent hip fracture, debility, incontinence and other current health conditions. The documented approaches included encourage to use call light for assistance, encourage resident to wait for assistance, keep call light in reach at all times, Tab alarm to bed and wheelchair. On [DATE] at 5:30 AM, a late entry documented in the nurse notes, the writer was called to the resident's room by a CNA who found Resident #3 on the floor "crawling position". Total body assessment done, no new bruises, Skin tears noted. Both hips without signs and symptoms of displacement. Resident #3 had no complaint of pain. After the assessment the resident was helped backed to bed. The nurses note dated [DATE] at 5:30 AM, lacked documented evidence the resident's vital signs were obtained, neurological checks were started, the resident's physician and family were notified of the fall. The nurses note lacked documented evidence the Tab alarm had been in place or if the skin tears had been addressed and for first aid given. On [DATE] at 7:05 AM, a nurses note documented, "...was called to room by CNA. CNA found skin tear to right elbow while getting Resident #3 up out of bed. The resident was not able to verbalize what had happened due to confusion. Area was cleansed with normal saline, pat dry and applied triple antibiotic ointment and covered with gauze. The resident's physician and family were notified..." The skin tear was documented as three centimeters (cm) length times one cm width. The clinical record lacked documented evidence Resident #3 was charted on every shift times 72 hours in accordance with the facility's policy on alert charting. The clinical record lacked documented evidence neurological checks had been completed. On [DATE] at 12:30 PM, a LN verbalized Resident #3 had a care plan for at risk for falls dated [DATE]. The care plan documented the Tab alarm was to be on bed and wheelchair. The LN verbalized the late entry dated [DATE], did not contain all the components needed in an assessment. The LN indicated there was no documentation the physician of family had been called and a full set of vital signs had not been documented. The LN was not able to locate documentation the neurological checks had been done per the facility's policy. The LN revealed there was no documentation the alert charting had been done after the fall times 72 hours. The LN revealed the entry in the nurses note dated [DATE] at 7:05 AM, was documentation she had written. The LN verbalized the nurse did not communicate about the fall and she was not aware the resident had fallen. The LN confirmed the care plan lacked documentation of new interventions put in place. The LN verbalized the facility's policy had not been followed. On [DATE] at 6:43 AM, nurse's notes documented Resident #3 fell at 3:30 AM, the resident's physician and family were notified. The resident had no injuries from fall. The resident was found on the door side of the bed on the floor with his head toward the head of the bed on right calling for his wife. "Bed alarm was not on when I entered room". The nurse's note dated [DATE], lacked documented evidence Resident #3 had been assessed after the fall for range of motion, vital signs, or neurological checks had been started. On [DATE] at 12:30 PM, a LN verbalized the documentation in the nurses note dated [DATE], lacked documentation vital signs were obtained, neurological checks had been done, or if the resident's range of motion had been evaluated. The LN revealed the care plan documented be sure the Tab alarm was on. The LN verbalized the care plan had not been updated. The LN confirmed the physician's orders [REDACTED]. The LN verbalized she was not able to locate documentation on the Medication Administration record (MAR) or Treatment Record for [DATE] the Tab alarm was in place per the physician's orders [REDACTED]. On [DATE] at 11:00 PM, a nurse note documented Resident #3 was found on the floor on right side next to window side of the bed with his head towards the head of the bed. Hospice, family and Director of Nursing notified. "Bed alarm was not engaged". The clinical record lacked documented evidence the resident was assessed after the fall for injuries, if the resident's range of motion had been evaluated, what the resident's vital signs were, if neurological checks had been started and if the Tab alarm was in place. The clinical record lacked documented evidence the resident had been charted on every shift times 72 hours in accordance with the facility's policy. The documentation on the neurological assessment flow sheet was dated [DATE] at 4:30 AM. The nurses note documented the resident fell at 11:00 PM on [DATE]. The clinical record lacked documented evidence neurological assessments had been done every 15 minutes for the first hour after the fall on [DATE] or every 30 minutes for the second hour after the fall, every one hour for the next third and fourth hours after the fall. On [DATE] at 12:30 PM, a LN verbalized the documentation in the nurses note from [DATE] lacked documentation of the resident's vital signs, if the resident had been assessed after the fall, if the resident's range of motion had been evaluated, and if neurological checks had been done. The LN indicated the care plan had not been updated after the fall. The LN revealed the physician's orders [REDACTED]. The LN was not able to locate documentation on the February 2013 Medication Administration Record or Treatment Record the Tab alarm was in place in accordance with the physician's orders [REDACTED]. On [DATE] at 1:30 PM, a nurse's note documented called hospice to notify of resident's fall last night. status [REDACTED]. The clinical record lacked documented evidence of when the fall occurred, how the fall occurred, where the fall occurred, if the resident had been assessed after the fall, what the vital signs were, if range of motion had been assessed and if the resident's physician and family had been notified. The clinical record lacked documented evidence the resident's Tab alarm had been in place. The clinical record lacked documented evidence the resident had been charted on every shift times 72 hours after the fall. The clinical record lacked documented evidence neurological assessments had been completed in accordance with the facility's policy. On [DATE] at 1:00 PM, a LN confirmed there was no documentation a full assessment had been done after the fall. The LN verbalized there was no documentation the Tab alarm was in place. The LN revealed there was no documentation when or where the fall had occurred. The LN verbalized there was no documentation the resident's physician, family or Hospice had been called after the fall. On [DATE] at 10:30 PM, the nurse notes documented a CNA found Resident #3 lying on the floor pad on his left side. Examined no injuries. Assisted to bed. "Wedge" was not in place and "bed alarm was not switched on". The clinical record lacked documented evidence Hospice, the family or the resident's physician had been contacted after the fall. The nurses notes lacked documentation of the resident's vital signs after the fall or if neurological checks had been done. The clinical record lacked documented evidence Resident #3's care plan had been updated after the fall. On [DATE] at 1:00 PM, a LN verbalized she did not know what a wedge was. The LN confirmed the physician's orders [REDACTED]. The LN confirmed the care plan had not been updated after the fall. On [DATE] in the morning, a Licensed Practical Nurse (LPN) verbalized she was not able to locate documentation the neurological assessments had been done after each fall. The LPN revealed she locate the documentation from neurological assessment flow sheets dated [DATE], [DATE] and [DATE] The Neurological Assessment flow sheet dated [DATE] lacked documentation a complete neurological assessment had been every 15 minutes for the first hour after the fall, or for every four hours for the remaining 24 hours after the fall. The Neurological Assessment flow sheet contained instruction which indicated staff were to document the date and time of each assessment. According to the flow sheet the guidelines were as follows: A. Every 15 minutes for the first hour after the fall. B. Every 30 minutes for the second hour after the fall. C. Every one hour for the next third and fourth hours after the fall. D. Every four hours for the remaining 24 hours after the fall. E. Once every 8 hours for the remaining 72 hours after the fall. The clinical record lacked documented evidence a Fall Risk Evaluation form had been completed after each fall. The clinical record contained a Fall Evaluation form which documented a fall Evaluation had been completed [DATE] and [DATE]. Resident #4 Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan dated [DATE] documented the resident was at risk for injury/falls related to. The care plan lacked documentation to determine the resident was a fall risk related to what condition. The documented approaches included encourage to use call light for assistance, encourage resident to wait for assistance, keep call light in reach at all times. The care plan contained documentation under the approaches low bed, bed alarm and mats on the floor next to bed. The care plan lacked documentation of when these interventions had been put in place and documented on the care plan. On [DATE] at 1:00 PM, the nurses notes documented Resident #4 was found sitting on the floor in the bedroom next to her bed around 7:25 AM. The resident was confused and lethargic, able to move all four extremities. Family and physician notified. The nurses note lacked documented evidence the resident's vital signs had been obtained and neurological checks had been initiated. The clinical record lacked documented evidence alert charting had been completed every shift times 72 hours after the resident's fall. The clinical record lacked documented evidence neurological assessments had been completed in accordance with the facility's policy after an unwitnessed fall. On [DATE] at 1:39 PM, a LN verbalized the nurses notes lacked documentation the resident's vital signs had been obtained after the fall on [DATE]. The LN confirmed clinical record lacked documented evidence alert charting had been completed every shift times 72 hours after the resident's fall or that neurological assessments had been completed in accordance with the facility's policy. On [DATE] at 12:30 PM, the nurse notes documented Resident #4 fell at around 9:00 AM. The NAT reported the resident was on the floor next to the bed. Assessment was done, able to move all four extremities, no bruising. Physician and family notified. The resident complained of right hip pain. The physician was notified and orders received to send the resident to the emergency room for x-ray of right hip due to fall. The nurses note dated [DATE] at 5:20 PM, documented the resident arrived back to the facility from the hospital at 1:15 PM. The resident did not have any broken bones or fractures. No new orders. Continue to monitor. The clinical record lacked documented evidence alert charting had been done every shift times 72 hours status [REDACTED]. On [DATE] at 1:39 PM, a LN confirmed the clinical record lacked documented evidence alert charting had been done every shift times 72 hours status [REDACTED]. A nurses note dated [DATE] at 9:00 AM, documented "late entry for [DATE]". Order received from physician to place a bed alarm and chair alarm. On [DATE] at 1:39 PM, a LN revealed the nurse had received the physician's orders [REDACTED]. The LN confirmed it was not appropriate to write a late entry for a physician's orders [REDACTED]. Complaint: NV 663

2 Based on interview, clinical record review and document review, the facility failed to ensure each resident had the necessary supervision and devices to prevent accidents for three of five sampled residents (Resident #1, # 3 and # 4). The facility failed to ensure their written policies for fall management, alert charting and neurological evaluations were followed for three of five sampled resident (Resident #1, # 3 and # 4). Findings include: The facility's policy entitled, Fall Management ( revised ,[DATE]), documented, the facility would implement a fall management plan based on the resident evaluation. #1. The nurse completes the Fall Evaluation at admission and quarterly before completing the Minimum Data Set (MDS). Residents, who were disorientated, confused or who had fallen in the past 3 months were also considered high potential for falls. Documentation entitled, Neurological Evaluation Policy dated ,[DATE], indicated in the event a resident had a fall and it was suspected or known the resident had bumped/hit their head, neurological evaluations were initiated and continued for 72 hours and the resident was placed on alert charting for 72 hours. Documentation entitled, Alert Charting Policy indicated the alert charting system was implemented when resident's experienced a change in condition. #1. The nurse was to evaluate the resident's condition when a change in condition/change from baseline was observed or reported. Examples included in part . abnormal vital signs, skin problems, vomiting, and falls. #6. The physician and resident's authorized representative were notified. The notification was documented in the resident's clinical record. #9. The care plan was updated when alert charting was discontinued. Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nurses note for Resident #1 dated [DATE] at 5:20 PM, documented Resident #1 was found on the floor by the side of the bed in her room. The note indicated the facility notified Hospice and family. Rendered first aid to left knuckle (skin abrasion). A Band-Aid was applied and the notes indicated the resident would be monitored. The nurses note dated [DATE] at 5:20 PM, lacked documented evidence Resident #1's vital signs were obtained, neurological checks had been initiated, or the resident's range of motion had been evaluated after the fall. The clinical record lacked documented evidence neurological checks had been done in accordance with the facility's policy after the fall at 5:20 PM. Documentation entitled Triage Communication (from the Hospice agency) documented on [DATE] hospice received a call from the facility at 5:06 PM, to report Resident #1 fell possibly from weakness or tripped over the oxygen tubing cord. The resident was not injured except a scrape on the left hand knuckle, which was cleaned and bandaged. Vitals after the fall Vitals blood pressure ,[DATE], heart rate 102, respirations 24, oxygen saturation 87% on 4 liters of oxygen and Resident #1's urine was dark. The facility indicated the resident had an upper respiratory infection. On [DATE] at 7:16 PM, the facility called hospice to report Resident #1's vitals: blood pressure was ,[DATE], heart rate 99, oxygen saturation 94% on 4 liters of oxygen. Resident #1 was feeling better after a nebulizer treatment, but tired. Xanax (anti-anxiety medication) to be given with night medications and Lasix would be withheld due to resident dehydration. The clinical record lacked documented evidence the Fall Risk Assessment had been completed after the fall [DATE] at 5:20 PM. The clinical record lacked documented evidence Resident #1's fall risk care plan had been updated after the fall on [DATE] at 5:06 PM. On [DATE] at 8:30 PM, a nurses note for Resident #1 documented I heard resident call out and went to her room and found her kneeling by her bed. I examined her and went to get the CNA (Certified Nursing Assistant) across the hall who placed her on the commode and left her w/ (with) instructions to use the call light when finished. We placed her back in bed and an incident report and initiated vitals to be taken from the resident. The clinical record lacked documented evidence Resident #1's family, physician or Hospice agency had been notified. The nurses notes lacked documentation Resident #1 had been assessed for injury, range of motion or the resident's vital signs after the fall. The clinical record lacked documented evidence neurological checks had been initiated or done in accordance with the facility's policy after the fall on [DATE] at 8:30 PM. On [DATE] at 8:45 PM, the nurses note (a Licensed Practical Nurse) documented, the resident's (Resident #1) daughter had called at the nurses station and asked if I would go check on her mother's phone. I said I would and have her call me on it. When I arrived in the room the resident was half over the bed and I lifted her up and determined she was deceased by checking her carotid and peripheral pulses and her evey (sic) were open and pupils fixed. Her daughter called on her phone and I answered and informed her that I had bad news for her. She asked if her mother was passed and I said she had. On [DATE] at 11:45 AM, a Registered Nurse (RN) verbalized per the facility's fall protocol a resident had a Fall Risk assessment completed upon admission and after every fall and quarterly. After a fall the nurse obtained a set of vital signs, completed a neurological check, checked the resident's range of motion, and assessed the resident for injuries. The resident's physician, family and the facilities Director of Nursing (DON) were notified. The nurses notes should document the information that's a standard we go by. The RN verbalized an unwitnessed fall would include neurological checks and vital signs the first hour every 15 minutes, then the second and third hours neurological checks every 30 minutes and then checks every 4 hours times 24 hours. The RN revealed the care plan would document the new fall interventions along with the date and location of the fall. The RN verbalized the care plan was to be updated after each fall and the Fall Risk Evaluation completed after each fall. On [DATE] at 12:20 PM, a Licensed Nurse (LN) revealed the facility's policy on falls indicated a fall risk assessment was done upon admission and after a fall. The LN indicated if a resident fell the assessment should include the resident's orientation, what happened, the resident was checked for injures, range of motion, vital signs and neurological status. The LN verbalized all assessment information went into the nurses notes. The fall risk assessment would be completed and the care plan was updated after each fall. The LN verbalized the updated care plan included date of the fall, the intervention and location of the fall. The LN revealed the neurological checks were documented on the neurological flow sheet. The LN indicated there were certain time frames to check the neurological status. On [DATE] at 1:30 PM, a LN confirmed the clinical record lacked documented evidence the neurological checks had been completed on [DATE]. On [DATE] at 2:00 PM, Licensed Nurse (LN) #2 verbalized she had been familiar with Resident #1. The resident had been ill before the falls on [DATE]. The resident was weak and was on antibiotics. LN# 2 verbalized the resident required someone to be with her when she was on the bedside commode due to her weakness. Licensed Practical Nurse (LPN) #2 revealed the resident fell because a CNA had put the resident on the bedside commode and left her alone. LN #2 indicated she had been told by LN #1 who was assigned to Resident #1, the resident had fallen earlier in the day on [DATE], and later on that day the CNA had left the resident on the bedside commode. The resident was told the resident to use the call light when she was ready to get off the commode. LN #1 told her the call light was on and asked the CNA to answer the call light. LN #1 verbalized she had entered the resident's room and the resident was on the floor. During the interview on [DATE], LN # 2 verbalized LN #1 told her she had gone into the resident's room later on and the resident was sitting up in the bed bent forward. LN #1 had spoken with the resident's family member on the telephone and told the family member I am sorry to tell you this but she is gone. LN #2 verbalized per the facility's policy the LPN was to have called a Registered Nurse and if the resident was on Hospice to call the Hospice agency. On [DATE] at 2:10 PM, a LN revealed the policy on falls indicated the resident was assessed for range of motion, bleedings, vital signs, level of conscious, if the fall was witnessed or unwitnessed. The LN verbalized if a fall was unwitnessed neurological checks were to be done. The LN indicated the documentation should include the family and physician or Hospice were notified, the resident was to be charted on every shift times 3 days and a fall risk assessment was done after each fall. The LN verbalized the resident's care plan was to be updated with new interventions. The LN verbalized the person who left Resident #1 on the bedside commode was a Nursing Assistant in Training (NAT) at the time of the fall not a CNA. On [DATE] at 9:10 AM, a CNA verbalized Resident #1 required one person assist and if the resident was weak the resident should not be on the bedside commode alone. On [DATE] at 9:29 AM, a CNA verbalized Resident #1 required assistance with transfers and was not to be left alone on the bedside commode because she was sick and weak. On [DATE] at 10:59 AM, a CNA revealed she was a Nursing Assistant in Training when she had taken care of Resident #1 on [DATE]. The CNA verbalized Resident #1 required assistance with transfers and toileting. The CNA revealed Resident #1 had a respiratory issue and complained of not being able to breathe prior to her fall. The resident had also complained of congestion, was weak and felt tired. The CNA verbalized she had put the resident on the bedside commode and gave her the call light to call for assistance. Resident #1 had told her it was okay to leave her. The CNA verbalized she left the room to assist another resident and asked the nurse to assist Resident #1 or call when the resident was done on the bedside commode. The CNA indicated the nurse was outside the resident's room passing medications and was going into the resident's room to give medications. The CNA verbalized the nurse came into the room where she was helping the other resident and told her she needed to take care of Resident #1 she had fallen. The CNA verbalized Resident # 1 was on her knees and leaning over the bed. The CNA revealed she assisted Resident #1 back into the bed and made safe in bed with oxygen on and took the resident's vitals. The CNA indicated when she emptied the bedside commode the resident's urine was dark in color and smelled. During the interview on [DATE], the CNA verbalized at the facility the CNA's were assigned a hallway and they all were to assist the residents. The CNA verbalized she was not aware Resident #1 had fallen earlier that day. The CNA revealed she was a Nursing Assistant in Training (NAT) at the facility when Resident #1 had the fall. The CNA revealed as a NAT she was not to be alone with residents and a CNA should have been with her. The CNA verbalized per the facility's policy the CNA's were not to leave a resident alone on the commode when the resident felt ill or were sick. The CNA revealed the facility's policy was a NAT was not to be alone with a resident. The CNA verbalized she had just received her CNA certification on Sunday. On [DATE] at 1:25 PM, a LN confirmed the clinical record lacked documented evidence neurological assessments had been completed on [DATE] after Resident #1's fall. On [DATE] at 12:10 PM, LN #1 stated she was familiar with Resident #1. LN #1 verbalized on [DATE] Resident #1 was ill, the resident had an upper respiratory infection or pneumonia. The LPN verbalized she had brought the resident in tea from home because she liked it and she knew the resident was dehydrated. LN #1 indicated she knew this because of the resident's skin turgor, the resident was emaciated looking and it had been told to her in shift report. LN #1 indicated she was not at the facility when the resident fell on [DATE] at 5:20 PM, but she was on the unit when the resident fell on [DATE] at 8:30 PM. LN #1 verbalized the documentation in the clinical record it was most accurate and a description of what had happened that night. LN #1 verbalized she did work with a NAT on [DATE] on the shift. LN #1 indicated per the facility's policy a NAT was supposed to be accompanied by a CNA and a NAT could not be alone with a resident. LN #1 indicated she did not know that at the time. Resident #3 Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE], the admission orders [REDACTED]. The clinical record contained a care plan dated [DATE], for Resident #3 was at risk for injury/falls related to recent hip fracture, debility, incontinence and other current health conditions. The documented approaches included encourage to use call light for assistance, encourage resident to wait for assistance, keep call light in reach at all times, Tab alarm to bed and wheelchair. On [DATE] at 5:30 AM, a late entry documented in the nurse notes, the writer was called to the resident's room by a CNA who found Resident #3 on the floor crawling position. Total body assessment done, no new bruises, Skin tears noted. Both hips without signs and symptoms of displacement. Resident #3 had no complaint of pain. After the assessment the resident was helped backed to bed. The nurses note dated [DATE] at 5:30 AM, lacked documented evidence the resident's vital signs were obtained, neurological checks were started, the resident's physician and family were notified of the fall. The nurses note lacked documented evidence the Tab alarm had been in place or if the skin tears had been addressed and for first aid given. On [DATE] at 7:05 AM, a nurses note documented, .was called to room by CNA. CNA found skin tear to right elbow while getting Resident #3 up out of bed. The resident was not able to verbalize what had happened due to confusion. Area was cleansed with normal saline, pat dry and applied triple antibiotic ointment and covered with gauze. The resident's physician and family were notified. The skin tear was documented as three centimeters (cm) length times one cm width. The clinical record lacked documented evidence Resident #3 was charted on every shift times 72 hours in accordance with the facility's policy on alert charting. The clinical record lacked documented evidence neurological checks had been completed. On [DATE] at 12:30 PM, a LN verbalized Resident #3 had a care plan for at risk for falls dated [DATE]. The care plan documented the Tab alarm was to be on bed and wheelchair. The LN verbalized the late entry dated [DATE], did not contain all the components needed in an assessment. The LN indicated there was no documentation the physician of family had been called and a full set of vital signs had not been documented. The LN was not able to locate documentation the neurological checks had been done per the facility's policy. The LN revealed there was no documentation the alert charting had been done after the fall times 72 hours. The LN revealed the entry in the nurses note dated [DATE] at 7:05 AM, was documentation she had written. The LN verbalized the nurse did not communicate about the fall and she was not aware the resident had fallen. The LN confirmed the care plan lacked documentation of new interventions put in place. The LN verbalized the facility's policy had not been followed. On [DATE] at 6:43 AM, nurse's notes documented Resident #3 fell at 3:30 AM, the resident's physician and family were notified. The resident had no injuries from fall. The resident was found on the door side of the bed on the floor with his head toward the head of the bed on right calling for his wife. Bed alarm was not on when I entered room. The nurse's note dated [DATE], lacked documented evidence Resident #3 had been assessed after the fall for range of motion, vital signs, or neurological checks had been started. On [DATE] at 12:30 PM, a LN verbalized the documentation in the nurses note dated [DATE], lacked documentation vital signs were obtained, neurological checks had been done, or if the resident's range of motion had been evaluated. The LN revealed the care plan documented be sure the Tab alarm was on. The LN verbalized the care plan had not been updated. The LN confirmed the physician's orders [REDACTED]. The LN verbalized she was not able to locate documentation on the Medication Administration record (MAR) or Treatment Record for [DATE] the Tab alarm was in place per the physician's orders [REDACTED].>On [DATE] at 11:00 PM, a nurse note documented Resident #3 was found on the floor on right side next to window side of the bed with his head towards the head of the bed. Hospice, family and Director of Nursing notified. Bed alarm was not engaged. The clinical record lacked documented evidence the resident was assessed after the fall for injuries, if the resident's range of motion had been evaluated, what the resident's vital signs were, if neurological checks had been started and if the Tab alarm was in place. The clinical record lacked documented evidence the resident had been charted on every shift times 72 hours in accordance with the facility's policy. The documentation on the neurological assessment flow sheet was dated [DATE] at 4:30 AM. The nurses note documented the resident fell at 11:00 PM on [DATE]. The clinical record lacked documented evidence neurological assessments had been done every 15 minutes for the first hour after the fall on [DATE] or every 30 minutes for the second hour after the fall, every one hour for the next third and fourth hours after the fall. On [DATE] at 12:30 PM, a LN verbalized the documentation in the nurses note from [DATE] lacked documentation of the resident's vital signs, if the resident had been assessed after the fall, if the resident's range of motion had been evaluated, and if neurological checks had been done. The LN indicated the care plan had not been updated after the fall. The LN revealed the physician's orders [REDACTED]. The LN was not able to locate documentation on the February 2013 Medication Administration Record or Treatment Record the Tab alarm was in place in accordance with the physician's orders [REDACTED]. On [DATE] at 1:30 PM, a nurse's note documented called hospice to notify of resident's fall last night. status [REDACTED]. Continued on neurological checks. The clinical record lacked documented evidence of when the fall occurred, how the fall occurred, where the fall occurred, if the resident had been assessed after the fall, what the vital signs were, if range of motion had been assessed and if the resident's physician and family had been notified. The clinical record lacked documented evidence the resident's Tab alarm had been in place. The clinical record lacked documented evidence the resident had been charted on every shift times 72 hours after the fall. The clinical record lacked documented evidence neurological assessments had been completed in accordance with the facility's policy. On [DATE] at 1:00 PM, a LN confirmed there was no documentation a full assessment had been done after the fall. The LN verbalized there was no documentation the Tab alarm was in place. The LN revealed there was no documentation when or where the fall had occurred. The LN verbalized there was no documentation the resident's physician, family or Hospice had been called after the fall. On [DATE] at 10:30 PM, the nurse notes documented a CNA found Resident #3 lying on the floor pad on his left side. Examined no injuries. Assisted to bed. Wedge was not in place and bed alarm was not switched on. The clinical record lacked documented evidence Hospice, the family or the resident's physician had been contacted after the fall. The nurses notes lacked documentation of the resident's vital signs after the fall or if neurological checks had been done. The clinical record lacked documented evidence Resident #3's care plan had been updated after the fall. On [DATE] at 1:00 PM, a LN verbalized she did not know what a wedge was. The LN confirmed the physician's orders [REDACTED]. The LN confirmed the care plan had not been updated after the fall. On [DATE] in the morning, a Licensed Practical Nurse (LPN) verbalized she was not able to locate documentation the neurological assessments had been done after each fall. The LPN revealed she locate the documentation from neurological assessment flow sheets dated [DATE], [DATE] and [DATE] The Neurological Assessment flow sheet dated [DATE] lacked documentation a complete neurological assessment had been every 15 minutes for the first hour after the fall, or for every four hours for the remaining 24 hours after the fall. The Neurological Assessment flow sheet contained instruction which indicated staff were to document the date and time of each assessment. According to the flow sheet the guidelines were as follows: A. Every 15 minutes for the first hour after the fall. B. Every 30 minutes for the second hour after the fall. C. Every one hour for the next third and fourth hours after the fall. D. Every four hours for the remaining 24 hours after the fall. E. Once every 8 hours for the remaining 72 hours after the fall. The clinical record lacked documented evidence a Fall Risk Evaluation form had been completed after each fall. The clinical record contained a Fall Evaluation form which documented a fall Evaluation had been completed [DATE] and [DATE]. Resident #4 Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan dated [DATE] documented the resident was at risk for injury/falls related to. The care plan lacked documentation to determine the resident was a fall risk related to what condition. The documented approaches included encourage to use call light for assistance, encourage resident to wait for assistance, keep call light in reach at all times. The care plan contained documentation under the approaches low bed, bed alarm and mats on the floor next to bed. The care plan lacked documentation of when these interventions had been put in place and documented on the care plan. On [DATE] at 1:00 PM, the nurses notes documented Resident #4 was found sitting on the floor in the bedroom next to her bed around 7:25 AM. The resident was confused and lethargic, able to move all four extremities. Family and physician notified. The nurses note lacked documented evidence the resident's vital signs had been obtained and neurological checks had been initiated. The clinical record lacked documented evidence alert charting had been completed every shift times 72 hours after the resident's fall. The clinical record lacked documented evidence neurological assessments had been completed in accordance with the facility's policy after an unwitnessed fall. On [DATE] at 1:39 PM, a LN verbalized the nurses notes lacked documentation the resident's vital signs had been obtained after the fall on [DATE]. The LN confirmed clinical record lacked documented evidence alert charting had been completed every shift times 72 hours after the resident's fall or that neurological assessments had been completed in accordance with the facility's policy. On [DATE] at 12:30 PM, the nurse notes documented Resident #4 fell at around 9:00 AM. The NAT reported the resident was on the floor next to the bed. Assessment was done, able to move all four extremities, no bruising. Physician and family notified. The resident complained of right hip pain. The physician was notified and orders received to send the resident to the emergency room for x-ray of right hip due to fall. The nurses note dated [DATE] at 5:20 PM, documented the resident arrived back to the facility from the hospital at 1:15 PM. The resident did not have any broken bones or fractures. No new orders. Continue to monitor. The clinical record lacked documented evidence alert charting had been done every shift times 72 hours status [REDACTED]. On [DATE] at 1:39 PM, a LN confirmed the clinical record lacked documented evidence alert charting had been done every shift times 72 hours status [REDACTED]. A nurses note dated [DATE] at 9:00 AM, documented late entry for [DATE]. Order received from physician to place a bed alarm and chair alarm. On [DATE] at 1:39 PM, a LN revealed the nurse had received the physician's orders [REDACTED]. The LN confirmed it was not appropriate to write a late entry for a physician's orders [REDACTED]. Complaint: NV 663

Based on interview, clinical record and document review, the facility failed to provide adequate hydration to prevent dehydration for two residents (Residents #1 and #2). Findings include: Resident #1 Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 7/15/12, a telephone order for Resident #1 from the physician documented, flush [DEVICE] (gastrostomy tube) with 250 cc (cubic centimeters) of water every shift. The Enteral Flow Sheet for Resident #1 dated July 2012, documented the following information of water flushes via [DEVICE] per shift on 7/10/12 through 7/26/12: 7/10/12 per shift -30 cc -30 cc -30 cc 7/11/12 per shift -30 cc -30 cc -30 cc 7/12/12 per shift -30 cc -30 cc -30 cc 7/13/12 per shift -30 cc -30 cc -30 cc 7/14/12 per shift -0 cc -30 cc -30 cc 7/15/12 per shift -200 cc -200 cc -200 cc 7/16/12 per shift -200 cc -200 cc -200 cc 7/17/12 per shift -200 cc -200 cc -120 cc 7/18/12 per shift -0 cc -200 cc -120 cc 7/19/12 per shift -0 cc -200 cc -200 cc 7/20/12 per shift -250 cc -200 cc -200 cc 7/21/12 per shift -250 cc -250 cc -250 cc 7/22/12 per shift -250 cc -250 cc -250 cc 7/23/12 per shift -250 cc -250 cc -illegible 7/24/12 per shift -250 cc -200 cc -0 cc 7/25/12 per shift -0 cc -200 cc -0 cc 7/26/12 per shift -0 cc -200 cc -0 cc The facility policy for Enteral Feeding Written Orders-467 (dated 11/2012) documented a resident on [DEVICE] feedings should receive a minimum of 1050 cc to 1380 cc per day of free water through the gastrostomy tube in conjunction with the tube feedings and water during the medication pass. The policy for Enteral Feeding Written Orders was dated after Resident #1 was transferred to the acute care facility. On 2/15/13 in the morning, the Director of Nurses (DON) was requested by telephone to send the policy for Enteral Feeding and the Hydration policies that were in effect when Resident #1 was at the facility in July 2012. The Director of Nurses indicated the facility did not have a specific policy for enteral feeding. The DON indicated the facility followed the program from (Name of Company) Enteral Nutritional program. A form, "Hydration Management", documented nursing would complete a hydration status assessment and develop an appropriate intervention for each patient. Patients were to receive adequate liquids to maintain optimal hydration. The form further documented dietary/nursing personnel would establish a plan of care for adequate hydration management that will help to assure maintenance of the optimum level of hydration. All patients will be monitored for actual fluid intake per facility protocol. The facility failed to monitor the proper free water intake for Resident #1. Resident #1 was transferred to the acute care facility on 7/27/12 via ambulance to the Emergency Department. Resident #1 was diagnosed with [REDACTED]. The resident's laboratory studies from the ED on 7/27/12 documented, potassium 6.5 (normal 3.5 to 5.2), sodium 149 (normal 133-144 high indicative of dehydration), blood urea nitrogen 105 (normal 8-20), creatinine 3.80 (normal 0.6-1.2). The physician's progress notes for Resident #1 dated 8/01/12, documented the resident appeared to be doing much better after hydration with intravenous fluids and free water 250 cc five times per day as ordered. The resident's mucus membranes were described as moist. Resident #1 was discharged from the acute care hospital to the facility on [DATE]. The discharge summary from the physician indicated the resident, upon discharge, was more awake, with spontaneous hand movements and facial movements. The resident's sodium was corrected with an increase in free water and at the time of the resident's discharge the electrolytes were stabilized with a sodium of 143 and a potassium of 4.2. The summary documented the resident had clinically improved and stable and ready for discharge. The physician indicated in the discharge summary dated 8/02/12 Resident #1, must have free water [MEDICATION NAME] of 250 cc of water five times per day. On 2/19/13, at 9:10 AM, a phone interview with the Registered Dietitian (RD) was conducted. The RD indicated she had been contracted with the facility since April 2012. The RD provided resident visits three times a month. The RD explained the recommended fluid intake was based on the resident's weight and food/fluid restrictions. The RD indicated in general, a total of 1500 cc of fluids per day was recommended. The RD explained the recommended calorie intake of [MEDICATION NAME] (nutritional supplement) and care plan may be found in the resident's records. The RD advised the global criteria for nutrition recommendation were food, fluid and medical condition. Resident #2 Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. Review of Nurses's Notes dated 11/18/12, at 5:47 PM, Resident #2 was transferred to a local acute care hospital due to lethargy and an oxygen saturation of 85% on room air. Review of Emergency Department (ED) admission orders [REDACTED]. Resident #2 had a Foley catheter upon transfer. Resident #2's laboratory tests performed at the ED on 11/18/12 documented: Sodium 152 - high indicative of dehydration (normal 133-148), chloride 116 - high (normal 98-110), blood urea nitrogen (BUN) 38 - high (normal 8-25), creatinine 1.80 - high (normal 0.5-1.5). Review of Discharge/Transfer Summary from the local acute care hospital dated 11/21/12 documented Resident #2 was discharged with [DIAGNOSES REDACTED]. Discharge laboratory data reported: Sodium 139, chloride 105, BUN 25, creatinine 1.4, all within normal limits. Resident #2 was transferred to a skilled nursing facility in Las Vegas for further intravenous treatment and rehabilitation. On 12/24/12, the skilled nursing facility in Las Vegas documented Resident #2 was maintained on transfer medications; dehydration was treated with IV fluids; hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION] were controlled with medications. Resident #2 was discharged to an extended care facility. Review of Hydration Program Policy (dated 11/2012) documented: "...Residents are provided a minimum of 480 cc at each meal (1440 cc per day) unless contraindicated by order for fluid restriction..." Review of Resident Care Plan dated 6/28/12, revised on 9/25/12, with target date of 12/24/12, documented Resident #2 was at risk for fluid volume overload related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The care plan's goal was to maintain fluid balance over current assessment period. The care plan recommended: "Provide at least 1500 cc of fluids daily with meals." Review of Physician order [REDACTED]. Review of meal monitor flowsheets revealed average daily fluid intake for June 2012 was 900 cc, July 2012 was 639 cc, November 2012 was 952 cc. During the investigation, the facility was unable to provide the meal monitors for August, September and October 2012. Review of Nutritional Progress Notes dated 10/22/12 documented: "...Excellent by mouth (PO) intake of food and fluids at meals. [MEDICATION NAME] noted in Rx..." The nutritional notes did not document if the RD had concerns about resident's actual fluid intake that was lower than recommended, while being administered [MEDICATION NAME] 40 milligrams once a day from 6/26/12 to 11/18/12. On 2/19/13, phone interview with the registered dietitian (RD). The RD advised limited recollection of Resident #2 without looking at the clinical records. When asked if the RD had concerns about the resident being administered [MEDICATION NAME] 40 milligrams daily as noted in the nutritional notes, the RD stated any recommendations or concerns were discussed with the Director of Nurses. The RD explained: "If Resident #2 had been okay with the same amount of fluid, then dehydration could have been caused by other medical conditions." In summary, the facility failed to ensure Resident's #1 and #2 received sufficient fluid to prevent dehydration. Complaint #NV 999 Complaint #NV 094