Every finding on record at Premier Health & Rehabilitation Center of LV, LP

Based on observation, interview, record review, and document review, the facility failed to ensure nursing staff completed required steps when a resident was discharged against medical advice (AMA). Specifically, there was no documentation of: (1) a discussion of the risks associated with leaving; (2) a signed AMA form; and (3) notification of the physician and the administrator or director of nursing for 1 of 8 sampled residents (R1). The deficient practice placed the resident at risk for an unsafe or uncoordinated discharge, which could have resulted in unmet care needs or rehospitalization.Findings include:Resident 1 (R1) was admitted on [DATE] with diagnoses including narcolepsy without cataplexy (excessive daytime sleepiness without sudden loss of muscle tone), edema, type 2 diabetes mellitus and morbid obesity. R1 was admitted for physical and occupational therapies and continuation of medical management. R1 discharged AMA on 10/19/2025. A case management note dated 10/17/2025 documented the family wanted to take the resident home, but nurse practitioner verbalized family needed care giver training prior to discharge. Care giver training was scheduled for 10/20/2025.A health status note dated 10/19/2025 documented R1's family member demanded an in-person visit from the physician or nurse practitioner to discuss the resident's care. The Charge Nurse explained that providers did not come in on weekends unless the situation was emergent, and since R1 was stable, there was no reasonable rationale for transfer. The note documented the family member called 911, and EMS arrived approximately 10 minutes later, transferred the resident, and left without speaking to staff. The family member approached the nurses' station and stated, we are out of here, before leaving with the paramedics.On 12/19/2025 at 12:57 PM, the Director of Nursing (DON) explained the process for residents who wished to leave the facility AMA. An AMA form would have been explained along with the risks and why the doctor was not discharging the resident and signed by the resident. If the resident refused to sign the AMA form, it would have been documented. The DON confirmed the incident with R1 would have been considered a case of leaving against medical advice.On 12/19/2025 at 2:52 PM, a Licensed Practical Nurse (LPN) explained if a resident wanted to leave AMA, the resident would have talked with the doctor or charge nurse first. The LPN would have spoken with the resident about risks/benefits of leaving and explained how it was not safe because the resident could end up back at the hospital. If a resident still wanted to leave, they would have been asked to sign the AMA form, and informed the facility would not have provided transportation, a walker, or a wheelchair. After the resident left, LPN would have notified the physician and documented a progress note with the reason why the resident left AMA, that the risk/benefits were explained and who was notified.On 12/19/2025 at 2:58 PM, the Assistant Director of Nursing explained if EMS took a resident out of the building, staff would have been expected to find out why they were taking the resident, notify the physician and family, document the incident.On 12/19/2025 at 3:20 PM, a Certified Nursing Aide explained if a resident wanted to leave AMA a nurse would have been notified right away.On 12/19/2025 at 3:30 PM, the DON explained If a resident refused to sign the AMA form, two nurses would have witnessed the refusal, signed it and kept it on file, and documented the incident. The DON explained the expectation was for the nurse to speak with EMS, document the situation, contact the physician, and follow the AMA policy. The DON verbalized that the nurse had called the physician, but there was no documentation of the call. The medical record lacked documented evidence of a signed AMA form and documentation that the risks and benefits were explained to R1 and their family.On 12/19/2025 at 3:39 PM, RN5 recalled the AMA discharge and explained that on the day of discharge, R1's family member said they would take R1 to the hospital for better care and demanded to speak with a provider face-to-face within 10 minutes. RN5 explained providers did not come to the facility on Sundays unless it was an emergency. RN5 stated they called the nurse practitioner, who said they were not coming. RN5 told the family, who said, thank you, and about 10 minutes later paramedics came and removed the resident. RN5 said R1 was stable. RN5 explained there was no documentation showing the provider had been contacted and did not recall calling again after R1 left. RN5 said another employee let EMS in through the side door, and no one spoke to EMS about the resident or the discharge. RN5 stated EMS just showed up, and RN5 did not notice them until they were leaving. RN5 said the Administrator, DON, and physician were normally notified per protocol but was unsure if it was documented.On 12/19/2025 at 4:11 PM, the DON explained when EMS came to the facility, they pushed a button located at the side door, which rang at the nurses' station, and staff then let them in. EMS did not have a code for self-entry and did not enter through the front doors.On 12/19/2025 at 4:17 PM, Registered Nurse 6 (RN6), explained EMS entered the facility through the side door. RN6 stated, EMS pressed a button outside the door and an audible buzzer alarmed at the nurses' station. The nurse or charge nurse would then look at the door cameras visualize who was at the door prior to letting them in. RN6 stated only the nurse or charge nurse allowed individuals entry through the side door; CNAs did not open the door without a nurse's permission. Once the nurse or charge nurse confirmed it was safe, they used the speaker system to verbally instruct EMS to enter. The facility's policy titled Against Medical Advice (AMA) dated 03/2023, documented when a resident or resident's representative expressed the desire to leave the facility before the attending physician had discharged the resident the nurse shall notify the physician and administrator and/or the director of nurses. Risks of leaving would be discussed, documented and the AMA form signed and placed in the resident's medical record. Should the resident or resident's representative refuse to sign the form, a clinical staff member signed the form, and a clinical staff member witnessed. The refusal to sign would also be documented.

Based on observation, record review, and interview, the facility failed to obtain a physician order, instructions for use, and monitoring for a soft neck collar for 1 of 17 sampled residents (Resident 95). The deficient practice had the potential to place residents at risk of potential injury from improper use of a soft neck collar.Findings include:Resident 95 (R95) was admitted [DATE], with diagnosis including encounter for surgical aftercare following surgery on the nervous system, complete lesion at thoracic (T) vertebrae T2-T6 level of thoracic spinal cord, and spinal stenosis cervical region.On 08/26/2025 at 10:27 AM, R95 was observed seated in bed wearing a soft neck collar. R95 was manipulating the collar with both hands, freely rotating it around the neck continuously. R95 stated had sustained a fall at home resulting in neck injury and subsequent neck surgery. R95 reported no staff at the facility were checking the placement or use of the neck collar.A Provider Encounter Progress Note dated 08/20/2025, documented patient may need a soft neck collar for support due to neck pain.A Case Management Note dated 08/21/2025, documented patient would benefit from continued therapy, offered soft neck brace ordered by rehabilitation. R95's medical record lacked documented evidence of a physician order, instructions for use, and monitoring for the soft neck collar. On 08/28/2025 at 2:12 PM, R95 was in bed awake. The soft neck collar was observed on R95's bedside table. R95 reported independently putting on and taking off the soft neck collar and stated would not wear in while lying in bed.On 08/28/2025 at 2:23 PM, the Wound Nurse, acknowledge R95's medical record lacked evidence of a physician order, instructions for use, and monitoring for the soft neck collar. The Wound Nurse explained there should have been a physician order including instructions for use and monitoring to prevent skin breakdown.On 08/28/2025 at 2:26 PM, the Rehabilitation Assistant explained if a neck collar was recommended, an order should have been placed for the neck collar including recommendation for R95 to wear the neck collar while out of bed. The order should have included monitoring of the neck collar. On 08/29/2025 at 10:26 AM, the Medical Records Director reported the facility did not have a policy for assistive devices including neck collars. On 08/29/2025 in the afternoon, the Director of Nursing (DON), confirmed the use of a soft neck collar required a physician order.

Based on observation, record review, document review, and interview, the facility failed to ensure a resident who experienced and reported pain received pharmacological interventions for pain management for 1 of 17 sampled residents (Resident 23). The deficient practice had the potential for residents not to receive pain relief.Findings include:Resident 23 (R23) was admitted [DATE], with diagnosis including multiple fractures of ribs right side, acute pain due to trauma, primary ortho arthritis right shoulder, and anterior displaced fracture of sternal end of right clavicle. The Minimum Data Set, dated [DATE], listed R23's primary medical conditions including acute pain due to trauma. The Minimum Data Set, dated [DATE], documented a Brief Interview for Mental Status score of 15, R23 was cognitively intact. On 08/26/2025 at 9:58 AM, R23 was lying in bed awake. R23 reported was in pain at a level of 8 on a 0/10 pain scale (0= no pain, 10 = worst pain). R23 explained the right shoulder was very painful and the pain medication provided was not strong enough. R23 reported had a painful hernia. On 08/27/2025 at 12:18 PM, R23 explained after admission, R23 was at the facility a few days without pain medication. R23 reported it took the facility a long time to set up pain medication. R23 stated would report pain, staff would say they would go check to see what they could provide for pain and would not return with pain medication. A Care Plan initiated 08/10/2025, revised 08/14/2025, documented R23 was at risk of pain related to fracture, right parietal scalp soft tissue swelling/hematoma (localized collection of blood), right 1st and 2nd rib fracture with accompanying trace apical pneumothorax (a collapsed lung) with adjacent subcutaneous emphysema (a progressive lung disease) and small volume hemothorax (an accumulation of blood), minimally displaced claviculate metaphyseal (part of the bone where growth happens) fracture, right diabetic foot ulcer, acute pain due to trauma, and pain and discomfort related to suspected non-reducible right inguinal hernia. A Pain assessment dated [DATE], documented pain occasionally, pain scale 8, and neck pain.An Encounter Note dated 08/11/2025, documented R23 reported a pain level of 4/10. A Health Status Note dated 08/13/2025, documented resident complained of pain and discomfort at right groin area, noted with slight bulge, swelling, discomfort when straining.A Situation Background Assessment Recommendation (SBAR), communication for changes in condition dated 08/13/2025, documented pain right groin, swelling started 08/13/2025. An Encounter Note dated 08/14/2025, documented patient complained of right groin/lower quadrant pain that had been ongoing for over 2 weeks. R23's medical record lacked documented evidence of a physician order for pain medication from admission to the facility on [DATE] until 08/16/2025.R23's medical record lacked documented evidence, R23 was administered pain medication from admission to the facility on [DATE] until the first administration of pain medication on 08/17/2025. On 08/27/2025 at 12:22 PM, a Licensed Practical Nurse (LPN), confirmed R23's medical record lacked a physician order for pain medication until 08/16/2025, when R23 requested a doctor and said was in too much pain to attend therapy. On 08/27/2025 at 12:36 PM, the Director of Nursing (DON), stated the expectation was R23's pain was to be treated. The DON explained a standing order for acetaminophen (a pain reliever) was available as an order that could have been placed at admission. On 08/27/2025 at 1:40 PM, the Nurse Practitioner (NP), reported there was a standing order for acetaminophen that could have been used for R23. The NP acknowledged an order for pain medication was not placed until 08/16/2025. The NP confirmed no pain medication was on order for R23 between 08/10/2025 and 08/16/2024.On 08/27/2025 at 2:00 PM, the Administrator confirmed the expectation was a resident's pain would be treated appropriately. A facility policy titled Pain Assessment and Management revised January 2025 stated based on the evaluation, the facility, in collaboration with the attending physician and other health care professionals, and the resident and/or his/her representative, develops, implements, monitors and revises as necessary interventions to prevent, reduce or manage each individual resident's pain, beginning at admission.

Based on interview and record review, the facility did not follow the Legionella Water Management Plan. Findings include:On 8/26/2025, the Maintenance Director stated the facility's Water Management Plan (WMP) was a work in progress that was in bits and pieces and provided the Legionella Water Management Plan.The Control Measures and Monitoring portion of the WMP stated No complaints about water taste or odor. No complaints about ice taste or odor. Water heaters are drained/flushed monthly. The taste and odor of water and ice was an inaccurate test of the presence of Legionella in water. The Maintenance Director explained there was no documentation of monthly flushes of the water tanks. The Maintenance Director provided logs of monthly water temperature testing. The water temperature logs did not specify an acceptable temperature range. The Ways to Intervene When Control Limits Are Not Met section of the WMP indicated a water specialized company would retest water and provide an assessment to determine if changes were needed.The facility provided a Final Report, dated 7/10/2025, for one environment culture test for Legionella for room [ROOM NUMBER] that was negative. The Maintenance Director explained room [ROOM NUMBER] was the furthest room from the water source.

Based on observation, interview, record review, and document review, the facility failed to ensure the free water flushes (FWF) via Percutaneous Endoscopic Gastrostomy (PEG) tube (a feeding tube inserted through the abdominal wall into the stomach and used to provide nutritional support and feed patients who are unable to eat or drink) were provided as prescribed for 3 of 4 sampled residents (Residents 53, 48, and 45). The deficient practice could have led to an increased risk of inadequate hydration, delayed wound healing, electrolyte imbalance and adverse health outcomes. Findings include: Resident 53 (R53) R53 was admitted on [DATE], with diagnoses including severe protein-calorie malnutrition, dysphagia (difficulty swallowing) and gastrostomy. A physician's order dated 08/22/2024, documented a water flush via PEG tube at 125 milliliter (ml) every 4 hours. A Care Plan dated 09/09/2024, documented R53 was at risk for dehydration related to nothing by mouth status. The PEG tube provided all fluids and nutrition. On 09/10/2024 at 10:29 AM, R53 was in bed with eyes closed, incoherent, and non-verbal. R53 was receiving infusions through the PEG tube, and was receiving 100 ml of water every 4 hours. On 09/10/2024 at 12:01 PM, R53 was in bed, the tube feeding (TF) pump was off, and the FWF were not infusing. On 09/10/2024 at 2:23 PM, R53 was in bed, the TF pump was off, and the FWF were not infusing. On 09/10/2024 at 4:17 PM, R53 was in bed, and the FWF were infusing at 100 ml every 4 hours at 12:00 PM and off at 9:00 AM, running for 21 hours. The LPN confirmed both the TF and water flushes had been provided late. On 09/11/24 at 8:48 AM, R53 was in bed with eyes closed and FWF were infusing at 100 ml every 4 hours. On 09/11/2024 at 1:28 PM, the Director of Nursing (DON) reviewed R53's enteral pump history and confirmed 242 ml of FWF had been infused over 24 hours, 643 ml over 48 hours, and 1,268 ml over 72 hours. The DON indicated the staff were expected to adhere to the prescribed TF orders. On 09/13/2024 at 1:19 PM, the Charge Registered Nurse (CRN) confirmed R53's FWF order was 125 ml every 4 hours, nothing per orem (NPO/ or nothing by mouth) and dependent upon TF. The CRN confirmed R53 FWF had not been completely infused as prescribed. On 09/13/2024 at 1:48 PM, the Registered Dietitian (RD) indicated R53's FWF were ordered at 125 ml every 4 hours, which equated to 36 ml/hour, totaling 750 ml in 24 hours, 1500 ml in 48 hours, and 2250 ml in 72 hours. The RD confirmed based on the enteral pump history report, R53's FWF were not completely delivered as prescribed. On 09/13/2024 at 2:45 PM, upon verification at the bedside, R53's FWF were infusing at 100 ml every 4 hours. The RD confirmed R53's FWF were ordered at 125 ml every 4 hours and not 100 ml. The RD indicated there was a significant discrepancy in R53's FWF and indicated R53 was at risk for dehydration and delayed wound healing if the order was not fully delivered as prescribed. Resident 45 (R45) R45 was admitted on [DATE], with diagnoses including dysphagia and gastrostomy. A Physician Order dated 08/08/2024, documented FWF via PEG tube at 150 ml every 4 hours. On 09/10/2024 at 12:01 PM, R45 was in bed with eyes open, the TF pump was turned off, and the FWF were not infusing. On 09/10/2024 at 2:23 PM, R45 was in bed with eyes closed, the TF pump was off, and the FWF were not infusing. On 09/10/2024 at 4:20 PM, the FWF was infusing at 100 ml every 4 hours. The LPN indicated the TF and FWF should have been turned on at 12:00 PM and off at 9:00 AM, running for 21 hours. The LPN confirmed R45's TF and FWF were provided late. On 09/11/2024 at 1:36 PM, the DON verified the enteral pump history, which indicated R45's FWF infused was 447 ml over 24 hours, 1047 ml for 48 hours, and 1472 for 72 hours. The DON indicated the staff were expected to follow the FWF as prescribed. On 09/13/2024 at 4:05 PM, the Charge Registered Nurse (CRN) confirmed R45's FWF were infusing at 100 ml every 4 hours, but the order was 150 ml every 4 hours. The CRN confirmed R45's FWF were not completely infused via PEG as prescribed. On 09/13/2024 at 4:15 PM, R45's FWF were infusing at 100 ml every 4 hours. The RD indicated R1 should have received a water flush at 150 ml every 4 hours, totaling 900 ml per day (a shortage of 453 ml), 1800 ml over 2 days (a shortage of 753 ml), and 2700 ml over 3 days (a shortage of 1228 ml). The RD explained the shortage accumulation could potentially lead to dehydration. The RD also indicated the staff were expected to infuse the FWF via PEG tube as prescribed. Resident 48 (R48) R48 was admitted on [DATE], with diagnoses including dysphagia and gastrostomy. A physician's order dated 08/09/2024 documented the FWF were to be administered at 75 ml every 4 hours via PEG tube. On 09/13/2024 at 4:05 PM, R48 was in bed and the FWF were infusing at 60 ml every 4 hours. The CRN confirmed R48's FWF should have been infusing at 75 ml every 4 hours. The CRN verified the actual total FWF infused was 150 ml over 24 hours, 300 ml over 48 hours, and 525 ml over 72 hours, confirming R48's FWF had been insufficiently infused. On 09/13/2024 at 4:15 PM, the Registered Dietitian (RD) confirmed R48 should have received 75 ml every 4 hours, not 60 ml. The RD confirmed R48's FWF were insufficiently infused resulting in a shortage of 825 ml over 72 hours. The RD indicated the nurses were responsible to verify the TF orders. A facility policy titled Tube Feeding, dated September 2021, documented to ensure the facility met nutritional guidelines and resident's nutritional requirements according to the physician's orders. The nursing staff were required to verify the order for tube feeding. A facility policy titled Assisted Nutrition and Hydration dated March 2023, documented to ensure that residents maintained acceptable parameters of nutritional status, were offered sufficient fluid intake to support proper hydration and health, and were provided a therapeutic diet when ordered. The policy also required that nutritional and hydration care and services be provided to each resident, consistent with their comprehensive assessment.

Based on observation, interview, record review, and document review, the facility failed to ensure the head of the bed was elevated to 30-45 degrees while the tube feeding (TF) was infusing and TF formula was delivered as prescribed for 4 of 4 sampled residents (Residents 53, 45, 48, and, 1) The deficient practice could have led to an increased risk of inadequate nutrition, weight loss, aspiration, and potential respiratory complications for the affected residents. Findings include: Resident 53 (R53) R53 was admitted on [DATE], with diagnoses including severe protein-calorie malnutrition, dysphagia (difficulty swallowing), and gastrostomy. The History and Physical dated 08/16/2024, documented R53 had severe dysphagia and the plan to continue Percutaneous Endoscopic Gastrostomy (PEG) tube (a feeding tube inserted through the abdominal wall into the stomach and used to provide nutritional support and feed patients who are unable to eat or drink) feeding for severe malnutrition and continue current feeding and other supplementation and recommendations per registered dietitian. The Nutritional assessment dated [DATE] documented a pending body mass index. R53 was NPO (nothing by mouth) with enteral nutrition of Glucerna 1.2 at 70 milliliters per hour (ml/hr.) providing 2016 kilocalorie's (kcal),101 gram (g) protein, and 1352 ml water. Nutritional interventions included maintaining NPO status and advancing to an oral diet as recommended. The tube feeding order was adjusted from 24 to 21 hours to allow time for therapy. A physician's order dated 09/10/2024, documented Glucerna 1.2 at 70 per hour x 21 hours (start at 12:00 PM and off at 9:00 PM) via PEG tube. To provide 1764 kcal and 88 g of protein. On 09/10/2024 at 10:29 AM, R53 was in bed in supine position with eyes closed, incoherent, and non-verbal. R53 received TF Jevity 1.2 via PEG tube and was infusing at 70 ml/hour. The TF bag was dated 9/10/2024. On 09/10/2024 at 12:01 PM, R53 was in bed, the TF pump was off, and nothing was infused. On 09/10/2024 at 2:23 PM, R53 was in bed, the TF pump was off, and nothing was infused. On 09/10/2024 at 4:17 PM, R53 was in bed, the TF Jevity 1.2 was infusing at 70 ml/hr. A Licensed Practical Nurse (LPN) indicated the TF should have been started at 12:00 PM and off at 9:00 AM, to run for 21 hours. The LPN confirmed the TF was infused late and the TF dose was not completely infused as prescribed. The LPN explained R53's head of bed should have been elevated at 45 degrees while the TF was infusing to prevent aspiration. On 09/11/2024 at 8:48 AM, the TF Glucerna 1.2 was infusing at 70 ml/hr. The TF bag was dated 09/11/2024. On 09/11/2024 at 1:28 PM, the Director of Nursing (DON) reviewed R53's enteral pump history and confirmed R53 received a total TF dose of 890 ml over 24 hours, 1924 ml over 48 hours, and 3076 ml over 72 hours. The DON indicated the staff should have followed the prescribed TF orders and ensured the resident's head of bed was elevated between 30-45 degrees. On 09/13/2024 at 1:48 PM, the Registered Dietitian (RD) confirmed the tube feeding (TF) of Glucerna 1.2 at 70 ml/hr. for 21 hours should have run from 12:00 PM to 9:00 AM daily. R53 should have received 1,470 ml over 24 hours, 2,940 ml over 48 hours, and 4,410 ml over 72 hours. The RD confirmed a TF dose discrepancy of 1,334 ml over 72 hours, while R53 only received 3,076 ml. On 09/13/2024 at 2:45 PM, the RD verified the TF dose delivery, confirming R53 was at risk for malnutrition, weight loss, and delayed wound healing if the prescribed order was not fully delivered over time. The RD indicated R53's body mass index remained stable at the time, with no significant weight changes. Resident 45 (R45) R45 was admitted on [DATE], with diagnoses including dysphagia and gastrostomy. A Physician Order dated 09/10/2024, documented Jevity 1.2 via enteral pump at 60 ml/hr. for 21 hours/day (start at 12:00 PM and stop at 9:00 AM) to provide 1512 kcal, 69 g protein. May use 1.5 if 1.2 not available. On 09/10/2024 at 2:45 PM, R45 was in bed in supine position and incoherent. The 1000 ml TF bag was hanging at bedside and not infusing at this time. Dated 09/10/2024, the TF formula bag contained approximately 718 ml. On 09/10/2024 at 4:26 PM, R45 was in bed with the head of the bed elevated at 10-15 degrees. The TF Jevity 1.2 was infusing at 60 cc/hr. and approximately 700 ml remaining in the bottle. The LPN confirmed R45's TF had been started late. The LPN explained R45's head of bed should have been elevated at 45 degrees while the TF was infusing to prevent aspiration. On 09/11/2024 at 8:05 AM, R45 was in bed, and the TF Jevity 1.2 was infusing at 60 ml/hr. On 09/11/2024 at 1:36 PM, the DON verified R45's enteral pump history and confirmed R45's total TF dose delivered was 920 ml over 24 hours, 2,052 ml over 48 hours, and 3,151 ml over 72 hours. The DON indicated the staff were expected to adhere to the prescribed TF orders. On 09/13/2024 at 2:01 PM, the RD indicated the TF order was Jevity 1.2 at 60 ml/hr. to run for 21 hours. The RD explained R45 should have received 1,260 ml in 24 hours, 2,520 ml in 48 hours, and 3,780 ml in 72 hours. The RD confirmed a discrepancy of 629 ml over 72 hours, resulting in a deficit in calories and protein due to the incomplete TF delivery. Resident 48 (R48) R48 was admitted on [DATE], with diagnoses including dysphagia and a gastrostomy. A physician order dated 09/13/2024, documented TF Jevity 1.2 should be provided at 60 ml/hr. via PEG tube for 21 hours daily, to start at 12:00 PM and stop at 9:00 AM, to provide 1512 kilocalories, 70 g of protein. On 09/13/2024 at 4:05 PM, the Charge Registered Nurse (CRN) confirmed R48's TF was infusing with Jevity 1.5 instead of Jevity 1.2. The CRN indicated the nursing staff were expected to administer the prescribed TF dose to prevent malnutrition or weight loss. The CRN confirmed the discrepancies in the enteral pump history revealed the following: 1102 ml over 24 hours, 2079 ml over 48 hours, and 3149 ml over 72 hours. On 09/13/2024 at 4:15 PM, the RD, confirmed R48 should have received TF dose of 3,780 ml over 72 hours with a discrepancy of 631 ml. The RD explained the cumulative shortages could lead to malnutrition and weight loss, and verbalized the importance of providing adequate protein and calories for nutrition. On 09/13/2024 at 4:20 PM, the Regional Consultant confirmed R48 had not documented any weight loss and had actually gained weight. Resident 1 (R1) R1 was admitted on [DATE] with diagnoses including dysphagia and a gastrostomy. A physician's order dated 04/19/2024, documented TF Jevity 1.2 via PEG tube at 60 ml/hr. running for 21 hours, to stop at 9:00 AM and start at 12:00 PM. On 09/13/2024 at 4:05 PM, the Charge Nurse (CRN) confirmed that R1's TF was infusing Jevity 1.2. The enteral pump history showed a total of 1,056 ml delivered over 24 hours, 2,075 ml over 48 hours, and 2,968 ml over 72 hours, all of which were below the prescribed TF volume. The CRN indicated the staff were expected to deliver the complete dose of the TF as ordered to prevent malnutrition or weight loss. On 09/13/2024 at 4:15 PM, the RD confirmed R1 should have received 1,260 ml over 24 hours (a shortage of 204 ml), 2,520 ml over 48 hours (a shortage of 445 ml), and 3,780 ml over 72 hours (a shortage of 812 ml). The RD indicated the staff were expected to administer the full TF dose to avoid potential malnutrition and weight loss due to the cumulative shortages. On 09/13/2024 at 4:20 PM, the Regional Consultant confirmed R1 was on Jevity 1.2 at 60 ml/hr. for 21 hours, from 12:00 PM to 9:00 AM. The consultant verbalized there was no documented weight loss, but rather, weight gain. A facility policy titled Tube Feeding, dated September 2021, required nursing staff to verify tube feeding orders to ensure the facility met the nutritional guidelines and the residents ' nutritional needs in accordance with the physician ' s orders. A facility policy titled Enteral Feeding-Safety Precautions dated December 2018, was documented to ensure the safe administration of enteral feeding. To prevent aspiration, the policy mandated elevating the head of the bed at least 30-45 degrees during tube feeding and for a minimum of 1 hour after feeding. The staff recognized the risks associated with aspiration, including the supine position.

Based on observation, interview and document review, the facility failed to ensure the kitchen vent hood, filters and dish machine were cleaned and maintained per policy. On 09/10/24 at 7:43AM, the initial kitchen observation revealed the following: -The kitchen vent exhaust hood filter with a copious amount of buildup. The Kitchen Manager indicated maintenance took care of the cleaning. -The dish machine had a copious amount of white and lime green build up on the exterior. The Dish Machine cleaning schedule was reviewed with the Kitchen Manager. The schedule documented the dish machine had been cleaned on 09/09/2024. The Kitchen Manager indicated the cleaning did not include the exterior. The Kitchen Manager verbalized; the dish machine appeared to be neglected. On 9/12/2024 at 11:14 AM, the Kitchen Manager showed that the oven, hood and dishwasher were cleaned. The Kitchen Manager explained the hood was cleaned quarterly by an outside company but then cleaned it themselves. On 9/13/2024 at 2:55 PM, the Maintenance Director indicated vent hood was cleaned every three months. The last cleaning was done on 05/29/2024 and the next cleaning due in September. The Maintenance Director indicated it was up to the dietary department to inform maintenance if the vent needed cleaning in between scheduled cleanings. The facility policy titled Hood and Filter - Operation and Cleaning, revised date 07/01/2016, documented the hood and filter system should be cleaned at least weekly, or more often as necessary. Due to potentially high fire hazard, it is important that hood filters are part of the cleaning schedule and are kept free of grease and dust. The facility policy titled Dish Machine Operation and Cleaning, revised 09/01/2021, documented on a weekly basis and as needed, clean the dish machine exterior with a deliming solution.

Based on observation, interview, record review and document review, the facility failed to ensure the IV (intravenous) heplock was monitored, or discontinued when not in use for 1 of 16 sampled residents (Resident 171). This deficient practice could have resulted in potential risks, including infection, infiltration and phlebitis. Findings include: Resident 171 (R171) R171 was admitted on [DATE], with diagnoses including acute kidney failure, hypertension and dehydration. The Activities Progress Notes dated 09/05/2024, documented R171 was alert, oriented and able to verbalize needs. The Wound/weekly Monitoring assessment dated [DATE], documented R171 had an IV implanted port on left hand back and present on admission. On 09/10/2024, at 1:41 PM, R171 was in bed and verbally responsive. R171 had an IV heplock on left hand back, which was covered with a transparent and undated dressing. R171 verbalized a nurse had placed the IV access 5 or more days ago but was not on IV medications. R171 did not understand the purpose of keeping the IV heplock. A Licensed Practical Nurse (LPN), confirmed the heplock was in place and was old, with undated dressing, peeling tape, and blood residue on the IV tubing. The LPN indicated an order was required for any IV line access. On 09/10/2024 at 1:43 PM, the Charge Registered Nurse (CRN) who admitted R171 confirmed the IV heplock on R171's left hand was in place. The CRN acknowledged there was no order, admission assessment, or care plan had been completed for the use of the IV heplock. The CRN indicated R171 had been admitted on [DATE] and likely had the IV access from the hospital. The CRN explained any IV access should have been assessed upon admission, with orders obtained or the IV discontinued if it was not necessary. The CRN explained the heplock should have been flushed or discontinued if not in use, highlighting the risk of infection if it was improperly managed. On 09/11/2024 at 4:20 PM, the Director of Nursing (DON) confirmed the wound nurse identified the IV heplock during skin assessment, but the order was neither transcribed nor obtained to discontinue the heplock, as R171 was not on IV medications. The DON indicated it was the charge or admission nurse's responsibility to ensure the completion of the appropriate assessment and orders. The DON indicated failing to monitor and remove the IV heplock when it was not in use could potentially lead to infection. On 09/12/24 at 10:55 AM, the Nurse Practitioner (NP) indicated all IV line access should have been properly assessed, monitored, and removed if not in use. The NP explained if a resident was admitted with an IV line, communication with the infectious provider should have occurred regarding the possibility of IV antibiotics. If IV antibiotics were not required, the IV line should have been removed due to the risk of infection. A facility policy titled Maintaining Patency of Peripheral and Central Vascular Access Devices, dated August 2021, documented a prescriber's order was necessary for IV management.

Based on observation, interview, record review, and document review, the facility failed to ensure the transmission-based precautions (TBP) and enhanced barrier precautions (EBP) were followed upon entering the rooms, and a garbage bin was available for 2 of 16 sampled residents (Residents 33 and 69). The deficient practice could potentially lead to the spread of infectious diseases, an increased risk of cross-contamination, and compromised health and safety for both residents and staff. Findings include: Resident 33 (R33) R33 was admitted on [DATE], with diagnoses including pressure ulcer of sacral region, malignant neoplasm, breakdown of nephrostomy catheter, and osteomyelitis. A Physician order dated 09/10/2024, documented R33 was on contact isolation precaution. A care Plan dated 09/10/2024, documented R33 had signs and symptoms of gastroenteritis manifested by frequent diarrhea or loose stools, vomiting, and other symptoms. On 09/10/2024 at 11:25 AM, R33's room had signage for contact precautions, PPEs were readily available by R33's entrance door. R33 indicated had diarrhea and was not feeling good. Upon exiting R33's room, a Licensed Practical Nurse (LPN) removed the used PPE, but there was no garbage bin available inside the room or by the door. The LPN indicated there should have been a designated garbage bin available for the TBP room. On 09/10/2024 at 11:34 AM, the Activities Assistant looked at the contact precaution signage at room [ROOM NUMBER], and entered the room with no PPE. The signage advised staff and visitors to perform hand hygiene, don gloves upon entering the room, don a gown, and observe hand hygiene before leaving the resident-care environment. The Activities Assistant entered, delivered R33's mail and exited R33's room without performing hand hygiene. The Activities Assistant confirmed the PPE had not been worn and hand hygiene had not been performed upon entering and exiting a TBP room. The Activities Assistant explained the precautions should have been followed to prevent cross contamination. On 09/1220/24 at 3:10 PM, the IP indicated R33 was placed on contact precaution for norovirus (a highly contagious virus causing vomiting, diarrhea, and stomach pain, often spread through contaminated food, water, or surfaces). The IP indicated hand hygiene was required prior to entering, and upon exiting the room, to don PPE, and gloves were required. The IP indicated a training regarding infection control was provided to the staff recently. The IP explained a garbage bin with a biohazard lining or red bag should have been available inside the room. The IP indicated the number of affected residents for norovirus had been increasing daily, and following the precaution was important to prevent cross-contamination. The Activities Assistant was expected to perform hand hygiene prior to entering and exiting the room, and PPE should have been worn upon entering the TBP room, especially when delivering mail from room to room. Resident 69 (R69) R69 was admitted on [DATE], with diagnoses including syphilitic oculopathy and neurosyphilis. A Physician Order dated 09/09/2024, documented R69 was placed on EBP due to a peripherally inserted central catheter (PICC) line. A Care Plan dated 09/09/2024, documented R69 was on EBP related to the PICC line. The interventions included the staff performing hand hygiene and wearing personal protective equipment (PPE) during contact activities. On 09/10/2024 at 10:29 AM, R69's room had Enhanced Barrier Precautions (EBP) signage posted by the door for bed A and the bed B was scribbled out but still visible. A Certified Nursing Assistant (CNA) changed the linens for R69 (bed B) while the resident was in the shower room. The CNA did not wear a gown while removing the soiled linens and replacing with new ones. The CNA confirmed a gown had not been donned because R69 was not on precautions, assuming only the resident in bed A was. The CNA later realized R69 had intravenous or a PICC line and was receiving IV medication, and a gown should have been worn for self-protection. The CNA acknowledged there was a significant risk of contamination if precautions were not properly followed. On 09/12/24 3:10 PM, the Infection Preventionist (IP) indicated was required to don a gown when changing the resident's soiled linens to prevent cross-contamination. The IP indicated an EBP precaution was in place for the resident with tubes such as catheters, tube feedings, IVs, and wounds. A facility policy titled Resident Isolation - Categories of Transmission-Based Precautions (undated) indicated that TBP precautions were to be used when caring for residents with communicable diseases or transmissible infections. Hand hygiene and the required PPE should have been performed and worn prior to entry and discarded upon exiting the TBP room.

Based on record review, interview and policy review, the facility failed to ensure quality of care delivery for 1 of 11 residents (Resident #1) by failing to document and notify a provider of significant changes in real time, failing to document facility required charting, and failing to demonstrate monitoring and documentation of the resident's status. Findings include: Resident 1 Resident 1 was admitted on [DATE], with metabolic encephalopathy, chronic hypoxemic respiratory failure, and schizoaffective disorder. On 9/11/2020, a provider ordered oxygen 3 liters per nasal cannula for shortness of breath each shift. On 9/12-13/2020, nursing notes documented the resident was on 3 liters per nasal cannula. On 9/14/2020, a C-reactive protein test and sedimentation rate showed abnormally high results, revealing a possible inflammatory process. These results were documented as entered for review before 2:30 PM. On 9/14/2020 at 2:48 PM, the ordering provider documented the initial history and physical, including the resident's latest carbon dioxide level was 44 (critically high), and the resident's saturation level was in the 60s this morning on 3 liters, increased to 6 liters on a facemask according to the nurse. The resident was comatose. The provider ordered to transfer the resident to acute care if no improvement in level of consciousness. The medical record lacked documented evidence the provider was either notified or made aware of the CRP and Sedimentation lab results. The medical record lacked documented evidence the provider was notified of the changes to the resident's oxygen delivery device and flow rate, when the changes occurred, how long they lasted and objective proof of medical stability in the form of improved saturation rates. The medical record lacked documented vital signs from after 10:00 AM on 9/14/2020 until the resident was admitted to acute care at 4:37 AM on 9/15/2020. The medical record revealed a nurse failed to complete documentation of a change of condition report directly related to the transfer, but mentioned a decrease in blood pressure and decrease in saturation from the high 80s to the low 80s. The medical record lacked documentation of any nursing notes or required charting for the entire overnight shift of 9/14-15/2020. The resident was transferred out the same night and admitted to acute care at 4:37 AM on 9/15/2020 with elevated carbon dioxide levels, profound hypoxia, multilobar pneumonia and septic shock. On 11/01/2023 at 10:15 AM, the ordering provider indicated could not remember if had reviewed the lab results or not, but the results could be indicative of an inflammatory process. The resident could be going septic. The ordering provider indicated nurses should notify providers when the oxygen delivery device and flow rate change and certainly for changes in condition. The ordering provider acknowledged there probably could have been a parameter defining the improvement in level of consciousness. On 11/01/2023 between 11:00 AM and 11:45 AM, a Registered Nurse (RN) and Licensed Practical Nurse (LPN) indicated some labs were faxed to a provider and some were not. Lab reports were also generally uploaded to the electronic record as they became available, but abnormal labs were relayed to providers in person or by phone whether they were abnormal or critical. The RN and LPN indicated a provider should be notified if there was a change in the oxygen delivery device and the flow rate. If saturations were in the 60s or 70s you would notify a provider. The RN and LPN thought it was necessary to seek clarification from the provider regarding what improvement in level of consciousness meant. The Oxygen Administration policy, last revised 7/01/2015, revealed nurses were allowed to initiate oxygen without an order in an emergency but notified providers as soon as possible afterward. Section VIII revealed the following to be documented in the medical record: A. Date and time oxygen was being used. B. Oxygen flow rate and device being used. C. Findings of physical assessment. D. Oxygen saturation levels as indicated. E. Resident's response to oxygen therapy. The Change of Condition Notification policy, last revised 1/01/2017, revealed the nurse was supposed to contact a provider with a significant change in the resident's physical condition, a need to alter treatment, resident's vital signs and document each shift for at least 72 hours. Complaint #NV00069677 Severity 3 Scope 1 37718 Interviews with three Certified Nurse Assistants, one Registered Nurse, one Licensed Practical Nurse, the Director of Staff Development, the Director of Nursing, the Medical Director, and the Administrator evidenced an understanding of the policies and procedures related oxygen therapy and change in resident condition. A review of the employee files of three Certified Nurse Assistants and one Licensed Practical Nurse indicated orientation training had included information on how to manage resident changes in condition including who and when to notify and what information to document. A review of the medical records for Residents #7, #8, #9, #10, and #11 in the setting of an emergency transfer to the hospital within the last six months indicated the residents were assessed and managed in a manner synonymous with the facility policies and procedures. The deficient practice occurred in 2020. Findings from the investigation revealed the facility had been in compliance since the prior recertification survey exit date of 09/14/2023 until 11/07/2023.

Based on record review, interview and policy review, the facility failed to administer oxygen treatments in a manner synonymous with its policies for 1 of 11 residents (Resident #1). Findings include: Resident 1 Resident 1 was admitted on [DATE], with metabolic encephalopathy, chronic hypoxemic respiratory failure, and schizoaffective disorder. On 9/11/2020, a provider ordered oxygen 3 liters per nasal cannula for shortness of breath each shift. On 9/12-13/2020, nursing notes documented the resident was on 3 liters per nasal cannula. On 9/14/2020 at 2:48 PM, the ordering provider documented the initial history and physical, including the resident's latest carbon dioxide level was 44 (critically high), and the resident's saturation level was in the 60s (normal range greater than 90%) this morning on 3 liters, increased to 6 liters on a facemask according to the nurse. The resident was comatose. The provider ordered to transfer the resident to acute care if no improvement in level of consciousness. The medical record lacked documented evidence the provider was notified of the changes to the resident's oxygen delivery device and flow rate, when the changes occurred, how long they lasted and objective proof of medical stability in the form of improved saturation rates. The resident was transferred out the same night and admitted to acute care with elevated carbon dioxide levels, profound hypoxia, multilobar pneumonia and septic shock. On 11/01/2023 at 10:15 AM, the ordering provider indicated nurses should notify providers when the oxygen delivery device and flow rate change. On 11/01/2023 between 11:00 AM and 11:45 AM, a Registered Nurse and Licensed Practical Nurse indicated a provider should be notified if there was a change in the oxygen delivery device and the flow rate. If saturations were in the 60s or 70s you would notify a provider. The Oxygen Administration policy, last revised 7/01/2015, revealed nurses were allowed to initiate oxygen without an order in an emergency but notified providers as soon as possible afterward. Section VIII revealed the following to be documented in the medical record: A. Date and time oxygen was being used. B. Oxygen flow rate and device being used. C. Findings of physical assessment. D. Oxygen saturation levels as indicated. E. Resident's response to oxygen therapy. The Change of Condition Notification policy, last revised 1/01/2017, revealed the nurse was supposed to contact a provider with a significant change in the resident's physical condition, a need to alter treatment, resident's vital signs and document each shift for at least 72 hours. Complaint #NV00069677 Severity 2 Scope 1 37718 Interviews with three Certified Nurse Assistants, one Registered Nurse, one Licensed Practical Nurse, the Director of Staff Development, the Director of Nursing, the Medical Director, and the Administrator evidenced an understanding of the policies and procedures related to oxygen therapy and change in resident condition. A review of the employee files of three Certified Nurse Assistants and one Licensed Practical Nurse indicated orientation training had included information on how to manage resident changes in condition including who and when to notify. A review of the medical records of Residents #8 and #11 with hypoxia in the setting of an emergency transfer to the hospital within the last six months, indicated the residents were assessed and managed in a manner synonymous with the facility policies and procedures. The deficient practice occurred in 2020. Findings from the investigation revealed the facility had been in compliance since the prior recertification survey exit date of 09/14/2023 until 11/07/2023.

Based on record review, interview and policy review, the facility failed to administer oxygen treatments in a manner synonymous with its policy for 1 of 11 residents (Resident #1). Findings include: Resident 1 Resident 1 was admitted on [DATE], with metabolic encephalopathy, chronic hypoxemic respiratory failure, and schizoaffective disorder. On 9/11/2020, a provider ordered oxygen 3 liters per nasal cannula for shortness of breath each shift. On 9/12-13/2020, nursing notes documented the resident was on 3 liters per nasal cannula. On 9/14/2020 at 2:48 PM, the ordering provider documented the initial history and physical, including the resident's latest carbon dioxide level was 44 (critically high), and the resident's saturation level was in the 60s this morning on 3 liters increased to 6 liters on a facemask, according to the nurse. The resident was comatose. The provider ordered to transfer the resident to acute care if no improvement in level of consciousness. The medical record lacked documented evidence the provider was notified of the changes to the resident's oxygen delivery device and flow rate, when the changes occurred, how long they lasted and objective proof of medical stability in the form of improved saturation rates. The resident was transferred out the same night and admitted to acute care with elevated carbon dioxide levels, profound hypoxia, multilobar pneumonia and septic shock. On 11/01/2023 at 10:15 AM, the ordering provider indicated nurses should notify providers when the oxygen delivery device and flow rate change. On 11/01/2023 between 11:00 AM and 11:45 AM, a Registered Nurse and Licensed Practical Nurse indicated a provider should be notified if there was a change in the oxygen delivery device and the flow rate. If saturations were in the 60s or 70s you would notify a provider. The Oxygen Administration policy, last revised 7/01/2015, revealed nurses were allowed to initiate oxygen without an order in an emergency but notified providers as soon as possible afterward. Section VIII revealed the following to be documented in the medical record: A. Date and time oxygen was being used. B. Oxygen flow rate and device being used. C. Findings of physical assessment. D. Oxygen saturation levels as indicated. E. Resident's response to oxygen therapy. The Change of Condition Notification policy, last revised 1/01/2017, revealed the nurse was supposed to contact a provider with a significant change in the resident's physical condition, a need to alter treatment, resident's vital signs and document each shift for at least 72 hours. Complaint #NV00069677 Severity 2 Scope 1 37718 Interviews with three Certified Nurse Assistants, one Registered Nurse, one Licensed Practical Nurse, the Director of Staff Development, the Director of Nursing, the Medical Director, and the Administrator evidenced an understanding of the policies and procedures related to oxygen therapy and change in resident condition. A review of the employee files of three Certified Nurse Assistants and one Licensed Practical Nurse indicated orientation training had included information on how to manage resident changes in condition including who and when to notify. A review of the medical records for Residents #8 and #11 with hypoxia in the setting of an emergency transfer to the hospital within the last six months indicated the residents were assessed and managed in a manner synonymous with the facility policies and procedures. The deficient practice occurred in 2020. Findings from the investigation revealed the facility had been in compliance since the prior recertification survey exit date of 09/14/2023 until 11/07/2023.

Based on record review and interview, the facility failed to demonstrate a physician was informed of abnormal results in a timely manner for 1 of 11 residents (Resident 1). Findings include: Resident 1 Resident 1 was admitted on [DATE], with metabolic encephalopathy, chronic hypoxemic respiratory failure, and schizoaffective disorder. On 9/14/2020, a C-reactive protein test and sedimentation rate showed abnormally high results, revealing a possible inflammatory process. These results were documented as entered for review before 2:30 PM. On 9/14/2020 at 2:48 PM, the ordering provider documented the initial history and physical, including the resident's latest carbon dioxide level was 44 (critically high), and the resident's saturation level was in the 60s this morning on 3 liters, increased to 6 liters on a facemask according to the nurse. The resident was comatose. The provider ordered to transfer the resident to acute care if no improvement in level of consciousness. The medical record lacked documented evidence the provider was either notified or made aware of the CRP and Sedimentation results. The resident was eventually transferred out and admitted to acute care with elevated carbon dioxide levels, profound hypoxia, multilobar pneumonia and septic shock. On 11/01/2023 at 10:15 AM, the ordering provider indicated could not remember if had reviewed the results or not, but the results could be indicative of an inflammatory process. The resident could be going septic. On 11/01/2023 between 11:00 AM and 11:45 AM, a Registered Nurse and Licensed Practical Nurse indicated some labs were faxed to a provider and some were not. Lab reports were also generally uploaded to the electronic record as they became available, but abnormal labs were relayed to providers in person or by phone whether they were abnormal or critical. Complaint #NV00069677 Severity 2 Scope 1 37718 Interviews with one Registered Nurse, one Licensed Practical Nurse, the Director of Staff Development, the Director of Nursing, the Medical Director, and the Administrator evidenced an understanding of the policy and procedure related to laboratory tests. A review of the employee files of one Licensed Practical Nurse indicated orientation training had included information how, when, and to whom to inform of laboratory test results. A review of the records of Residents #7, #8 and #11 with laboratory test results in the setting of an emergency transfer to the hospital within the last six months indicated the laboratory tests were reported in a manner synonymous with the facility policy and procedure. The deficient practice occurred in 2020. Findings from the investigation revealed the facility had been in compliance since the prior recertification survey exit date of 09/14/2023 until 11/07/2023.

Based on interview, record review and document review, the facility failed to ensure a timely notification of a Notice of Medicare Non-Coverage (NOMNC) for 1 of 3 sampled (Resident 10). The failure of a timely notification of a discharge could prevent a resident from filling an appeal to ensure the notice was within the criteria for discharge under Medicare skilled services. Findings Include: The Center for Medicare/Medicaid Services - CMS Form 10123 - NOMNC, documented you must make your request to the Quality Improvement Organization (QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end skilled services. Your request for an immediate appeal should be made as soon as possible , but no later than noon of the day before the effective date indicated on the form. Resident 10 (R10) R10 was readmitted on [DATE] with diagnoses including acute respiratory failure and pneumonia. Review of the NOMNC issued for R10 had a last cover date (LCD) dated for 04/14/2023 for skilled services for physical and occupational therapy. Notification of the [NAME] County Financial Guardian was completed on 04/13/2023 at 10:58 AM. 09/13/23 03:19 PM, the Social Services Assistant (SSA) confirmed the NOMNC was signed/completed a day prior to the LCD. The SSA indicated the minimum amount of time for notification of a beneficiary and/or beneficiary representative was two days prior of an LCD. The SSA indicated untimely notification of NOMNC can result in preventing acceptance of an appeal of a beneficiary or beneficiary representative to the QIO. If an appeal could not be processed the resident could have had a favorable result from a QIO review resulting to continuation of the proposed discontinuation of skilled services. The facility policy titled Transfer and Discharge (undated), documented the facility may use Notice of Proposed Transfer/Discharge or other comparable forms to provide a resident of his/her resident representative with advance notice of a transfer or discharge.

Based on interview, record review and document review, the facility failed to ensure resident belongings were inventoried prior to discharge from the facility for 1 of 21 sampled resident (Resident 273). The deficient practice had the potential of preventing misappropriation of property for a resident. Findings include: Resident 273 (R273) R273 was admitted on [DATE] and was discharged on [DATE] with diagnoses including fracture of the right arm shaft of the humerus and hypertensive heart disease. Review of R273's medical record revealed an Inventory of Personal Effect dated 04/14/2023. The items listed were for shirts, a watch, and a handbag. The form documented the resident refused to sign. Two employees provided the signature. The section for the: On Discharge/Move Out was left blank and was not competed to verify an exit inventory was completed. On 09/13/2023 at 1:00 PM, the director of nursing (DON) and the Administrator confirmed the finding. The DON indicated the chart was actually audited for the same findings. The DON acknowledged an exit inventory should have been completed. The team acknowledged a more detailed inventory of the handbag would have been beneficial. The DON acknowledged the facility had no means of determining if the contents of the handbag was missing. The facility policy titled Transfer and Discharge (undated), documented upon transfer or discharge of the resident, the facility will provide the resident or representative with the copy of the resident's property and have the recipient sign a receipt. Complaint #NV00068579

Based on interview, and document review the facility failed to ensure a resident was free from physical and verbal abuse for 1 of 21 sampled residents (Resident 2). The deficient practice had the potential to cause physical or psychosocial harm to the resident. Findings include: Resident 2 (R2) R2 was admitted on [DATE] with diagnoses including cerebral palsy, chronic kidney disease stage 3, and major depressive disorder. The facility reported incident (FRI) dated 09/08/2023, documented an incident from 9/04/2023 when a Certified Nursing Assistant (CNA) directed profanity towards a resident, pinned the resident's arms down and slammed the resident into the siderails. Law enforcement was notified, and the CNA was suspended during the investigation and eventually terminated. The CNA was reported to the Nevada State Board of Nursing. On 09/14/2023 at 12:29 PM, A Certified Nursing Assistant (CNA) indicated abuse training was completed upon hire and as needed. If the CNA witnessed staff abusing a resident the CNA would separate the staff and resident and would report the incident to the abuse coordinator. The CNA reported feeling comfortable reporting abuse to facility leadership. On 09/14/2023 at 12:38 PM, a Registered Nurse (RN) confirmed abuse training was provided upon hire and as needed. If the RN witnessed abuse the RN would separate individuals involved and report abuse to the abuse coordinator. The RN indicated feeling comfortable reporting abuse to facility leadership. CNAs can also report abuse to the charge nurse. On 09/14/2023 at 1:45 PM, the Administrator confirmed the abuse occurred. The Administrator indicated the CNA was suspended on 09/04/2023 and terminated on 09/08/2023. Additional abuse training was provided to staff following the incident. Interviews were conducted with staff, the resident of concern, and other residents. In-service training on abuse and caring for difficult patients was conducted on 09/04/2023. Review of R2's clinical record documented the resident's care plan was updated related to abuse on 09/05/2023. On 09/12/2023 through 09/14/2023, the facility's correction of the past non-compliance related to the incident occurred as evidenced by: -The facility suspended and terminated the CNA. -The facility notified the resident's family and physician. Filed a police report with law enforcement. -The facility reported the CNA to the nursing board. -The facility conducted Interviews with the CNAs involved, other staff members, the resident of concern, and other residents in the hallway. -The facility conducted in-service training on reporting abuse and caring for difficult patients on 09/04/2023 -CNA and nursing staff indicated abuse training was conducted upon hire and as needed. Staff explained abuse response and reporting procedures. -Nursing staff assessed R2 for signs of injury and psychosocial distress. -The facility updated R2's care plan related to the abuse dated 09/05/2023 Facility Reported Incident #NV00069355

Based on interview, record review and document review, the facility failed to provide documented evidence the investigation of an allegation of a resident-to-resident altercation was completed for 1 of 21 sampled residents (Resident 4); and an allegation of abuse was reported in a timely manner for 2 of 21 sampled residents (Resident 36 and 58). The deficient practice had the potential for the delay in the identification and prevention of similar incidents involving the same residents. Resident 4 (R4) R4 was admitted on [DATE], with diagnoses including unspecified psychosis not due to a substance or known physiological condition and obesity. The Situation Background Assessment/Appearance Recommendation (SBAR) form dated 03/19/2023 at 6:53 AM, documented the following: - Situation: R4 was found in another resident's room, verbally aggressive, looking for a cream colored clothing (blouse). Altercation with another resident. Another resident accused R4 of pushing the resident. There was no documented evidence the facility conducted a complete investigation of the alleged incident. The Facility Reported Incident (FRI) form dated 07/07/2023, documented an incident/allegation of physical abuse which occurred on 07/07/2023 at 3:26 AM. The nurse reported R4 and R8 were screaming at each other while R8 was sitting on a toilet and R4 was standing in front of R8. R8 later approached the nurse's station and reported R4 attacked R8 while sitting on the toilet by pulling R8's hair and pushing the resident's shoulder. On 09/13/2023 at 1:07 PM, an interview with the Administrator and the Director of Nursing (DON) was conducted regarding the alleged incident on 03/19/2023 which involved R4. The Administrator explained the nurse who completed the SBAR dated 03/19/2023, should have reported the incident to the Charge Nurse, who would have notified the Administrator immediately. The Administrator or the DON would have initiated an investigation and interviewed the residents and potential witnesses such as the nurses who worked when the alleged incident occurred. The DON indicated the alleged incident was a resident-to-resident altercation. The resident's care plan should have been updated depending on the outcome of the investigation. The Administrator and the DON were requested to provide documentation of the investigation conducted regarding the alleged incident on 03/19/2023. On 09/13/2023 at 1:52 PM, the Administrator provided a handwritten note which documented, Nurse reported resident to resident altercation with possible physical contact. Per the nurse, there was no actual physical contact that occurred after speaking to the victim. The Administrator confirmed signing the document. The handwritten note did not document the date when it was signed, name of the nurse, name of the residents involved, date of alleged incident. On 09/13/2023 at 2:00 PM, the Administrator explained when doing the investigation of an allegation of abuse or a resident-to-resident altercation, the Administrator or the DON would have interviewed the staff members and residents involved and obtained their statements. The names of the residents and staff members who were interviewed would have been documented and the date when the interview was conducted. The Administrator and the DON acknowledged the alleged incident which occurred on 03/19/2023 involving R4 was not thoroughly investigated. The Administrator confirmed the handwritten note mentioned above had no date when signed, names of the residents involved, name of the nurse interviewed, date when the interview was conducted, and date of the alleged incident. The Administrator acknowledged the investigation was not completed and the FRI was not submitted to the State. On 09/14/2023 at 3:06 PM, the DON explained the investigation should have been completed to rule out abuse and an initial report should have been submitted to the State. The facility's policy titled Abuse Prevention and Prohibition Program dated 10/24/2022, documented the facility promptly and thoroughly investigated reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or other criminal acts. Witness reports must have been given in writing and signed and dated. 29141 Resident 58 (R58) R58 was admitted on [DATE], with diagnoses including hypertension, atrial fibrillation, and chronic post-traumatic disorder. A nursing progress note dated 06/16/2023, recorded detailing an incident when a resident (R36) exhibited verbal aggressiveness against R58, who happened to be their roommate. R36 was seen making inappropriate remarks and using profanities. According to the progress note, R36 was redirected. Resident 36 (R36) R36 was admitted on [DATE], with diagnoses including hypertension, blindness, hearing loss. Review of the medical record revealed a change in condition evaluation dated 06/19/2023 that documented on June 16, 2023, staff members reported an incident involving R36 who displayed verbal aggression towards R58 (roommate). R36 was seen uttering improper comments and engaging in cursing behavior. A review of the facility incident investigation revealed the investigation was initiated on 06/19/2023, and reported to the pertinent authorities, family, and physician the same day. On 09/14/2023 at 3:30 PM, the Director of Nursing (DON) explained that during the chart audit, a nursing note was found documenting the incident. The DON indicated the investigation was initiated immediately and reported to the corresponding authorities. The DON acknowledged the nurses failed to report the incident as described in the facility policy and procedures since they did not believe an abuse occurred because the residents were friends and roommates. The DON confirmed the nurses were re-educated in the process of reporting abuse allegations timely. The facility's policy titled Abuse Prevention and Prohibition Program dated 10/24/2022, documented all staff were mandated reporters for abuse. The Administrator would report abuse, neglect, exploitation, mistreatment, injuries of unknown origin, misappropriation, or other incidents that qualify as a crime. The policy indicated incidents of alleged abuse should be reported no later than 24 hours to pertinent authorities if the allegation does not result in serious bodily injury. Facility Reported Incident #NV00068818

Based on interview, record review and document review, the facility failed to ensure a comprehensive assessment was completed in a timely manner for 1 of 21 sampled residents (Resident 4). The deficient practice had the potential for the delay in the identification and provision of the specific interventions for the resident's care and needs. Findings include: Resident 4 (R4) R4 was admitted on [DATE], with diagnoses including unspecified psychosis not due to a substance or known physiological condition and obesity. Review of R4's medical record revealed an annual Minimum Data Set (MDS) assessment had not been completed for 2023. On 09/13/2023 at 12:09 PM, the MDS Director confirmed the findings and acknowledged R4's annual MDS should have been completed on 08/13/2023. The MDS Director explained the annual MDS was a comprehensive assessment and should have been completed to develop the care plan and identify the specific interventions for the resident. The Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument (version 3.0 manual) dated October 2019, documented an annual assessment was a comprehensive assessment for a resident and must have been completed on an annual basis (at least every 365 days).

Based on record review, interview, and document review, the facility failed to make a referral to the State authority when a newly evident mental disorder was identified to perform a new Preadmission Screening and Resident Review (PASRR), for 5 of 21 sampled residents (Resident #16, #3, #22, #27, and #28). The deficient practice potentially placed the residents at risk for inappropriate placement with regards to the required level of care. Findings included: Resident#16 (R16) R16 was admitted on [DATE], with diagnoses including CVA, neurocognitive disorder and right hemiplegia. The Minimum Data Set (MDS) annual assessment dated [DATE], reflected R16 was not being considered for PASSR level 2 since the resident did not have a serious mental illness or mental retardation, however, under the diagnoses section (Section I) of the MDS, schizophrenia and depression were listed as part of the psychiatric disorders. A PASSR level 1 dated 01/22/14, revealed R16 was appropriate for placement in a nursing facility. The determination was based on the premise R16 did not have a mental illness, development disability or a related condition, or dementia. This screening was performed three years prior to R16's original admission on 03/24/2017. Level of Care (LOC) determination dated 01/31/2014, revealed an initial placement assessment and meet criteria for NF. A social services progress note dated 02/25/2020, revealed major depressive disorder and schizophrenia as R16's diagnoses. A psychiatric assessment dated [DATE], documented R16 had history of schizophrenia and major depressive disorder. A physician progress note dated 09/02/2023, revealed depression and schizophrenia as R16's diagnoses. On 09/13/2023 at 1:00 PM, the Assistant Social Worker confirmed R16 did not have a PASSR level 2, and a new application was just initiated. The Assistant Social Worker explained after R16 was diagnosed with schizophrenia and depression that a new PASSR determination should have been arranged. 48819 Resident 3 (R3) R3 was admitted on [DATE] with diagnoses including dementia without behavioral disturbances in psychotic feature, bipolar disorder, and major depressive disorder. Review of R3's clinical record documented the resident's PASARR level 1 was completed on 09/07/2021. The PASARR determination indicated R3 did not have mental illness, developmental delay, dementia, or related condition. Review of R3's clinical record documented an active diagnosis of bipolar disorder. A physician order for Depakote tablet delayed release 500 milligrams (mg), give one tablet by mouth every 8 hours for stabilizing related to bipolar disorder. The facility lacked documented evidence the resident was referred for a PASARR level 2. Resident 22 (R22) R22 was admitted on [DATE] with diagnoses including bipolar disorder current episode manic, anxiety, and hypertension. Review of R22's clinical record documented the resident's PASARR level 1 was completed on 08/18/2020. The PASARR determination indicated R22 did not have mental illness, developmental delay, dementia, or related condition. Review of R22's clinical record documented an active diagnosis of bipolar disorder. A physician order for Seroquel oral tablet 25 mg give 1 tablet by mouth at bedtime for bipolar disorder. The facility lacked documented evidence the resident was referred for a PASARR level 2. Resident 27 (R27) R27 was admitted on [DATE] with diagnoses including major depressive disorder, schizoaffective disorder, and anxiety disorder. Review of R27's clinical record documented the resident's PASARR level 1 was completed on 04/10/2020. The PASARR determination indicated R27 did not have mental illness, developmental delay, dementia, or related condition. Review of R27's clinical record documented an active diagnosis of schizoaffective disorder. The facility lacked documented evidence the resident was referred for a PASARR level 2. Resident 28 (R28) R28 was admitted on [DATE] with diagnoses including unspecified psychosis, chronic obstructive pulmonary disease, and cognitive communication deficit. Review of R22's clinical record documented the resident's PASARR level 1 was completed on 11/12/2019. The PASARR determination indicated R28 did not have mental illness, developmental delay, dementia, or related condition. Review of the clinical record documented an active diagnoses of unspecified psychosis. The facility lacked documented evidence the resident was referred for a PASARR level 2. On 09/14/23 at 8:30 AM, the Social Services Director (SSD) reported social services is not responsible for PASARR level 2 referrals. Residents receive pre-screening for PASARR level 1 prior to admission to the facility. The SSD indicated the PASARR level 2 referrals are completed by a licensed medical professional. The SSD could not provide a name or title of the person responsible for PASARR level 2 referrals. On 09/14/23 at 08:53 AM, the Administrator reported the facility does not currently have a process to refer residents who develop mental disorders after admission for a PASARR level 2. On 09/14/2023 at 8:53 AM, The Director of Nursing (DON) indicated the facility does not have a process to identify residents with requirements for a PASARR level 2 following admission and a negative PASARR level 1. The DON revealed the facility's expectation was for social services to complete referrals for PASARR level 2. Review of the Pre-admission Screening Resident Review (PASRR) policy revealed there were no facility policies to refer residents with newly evident mental disorders for a PASARR level 2.

Based on record review and document review, the facility failed to ensure a baseline care plan was developed in a manner that included interventions to prevent injuries related to falls for 1 of 21 sampled residents (Resident #62). The deficient practice had the potential to place the resident in a risk for fall-induced injuries. Findings include: Resident #62 (R62) R62 was admitted on [DATE], with diagnoses including recurrent falls, acute cerebrovascular accident (CVA), and diabetes. The Minimum Data Set (MDS) admission assessment dated [DATE], revealed R62 had severely impaired cognitions. Fall risk assessment dated [DATE], indicated R62 was at high risk for falls. The assessment documented a prevention protocol should be initiated immediately and documented on the care plan. The baseline care plan dated 06/24/2023, indicated R62 was at risk for falls related to gait and balance problems, incontinence, paralysis, and poor communication and comprehension. The approaches documented in the plan included anticipation and honor resident's needs, apply bolster to edge to act as a sensory boundary, and call light reachable. The baseline care plan did not include approaches such as low bed and floor mattresses to prevent injuries related to falls. A nursing progress note for change of condition dated 07/08/2023, revealed staff found R62 laying on the floor, unable to explain how the fall occurred. The note documented an assessment was performed and it was noted swelling on the right zygomatic bone (cheekbone or malar bone, located below and lateral to the orbit, or eye socket). The resident was assisted back to bed and complained of pain in the head, face, back, hips and legs. The note indicated R62 was advised to press the call light for assistance, placed the call light within reach, and the bed was placed in low position. The interventions post fall documented in the progress note included orders for ice pack, Xray of the head, face, back, hips and legs, neurological checks, and pain management. The nursing progress note did not document the bed was in low position and floor mattresses were in place beside the bed at the time the resident was found on the floor. An interdisciplinary team (IDT) post-fall evaluation dated 07/08/2023, documented R62 rolled and fell out of the bed on resident's left side. A bolster to be placed on R62's left side to act as sensory to the edge of the bed was the intervention documented in the evaluation. There was no documented evidence a floor mattresses and low bed were suggested as part of the interventions. The care plan for fall prevention documented the interventions were updated on 07/28/2023 to include floor mattress and low bed to minimize injury. This update occurred 20 days after R62 sustained a fall. A physician order dated 07/28/2023, documented floor mattress/ landing mattress and low bed to minimize injury, and bolster as sensory reminder to bed edge were ordered. These orders were placed 20 days after R62 sustained a fall. There was no documented evidence of previous orders for falls and injuries prevention. The facility policy titled Care Planning dated 10/24/2022, documented the care plan served as a course of actions where the resident, the attending physician, and the interdisciplinary team (IDT) worked to help the resident move toward resident-specific goals to address nursing, medical, mental, and psychosocial needs. The facility policy titled Fall Management Program dated 02/25/2018, indicated that based of the information gathered from the assessment, history and diagnoses, the nursing staff and the IDT would implement interventions to reduce the risk of falls.

Based on interview, record review, policy review, and document review, the facility: 1) Failed to ensure breathing treatments and oxygen were administered in accordance with physician's orders [REDACTED].#2). Findings include: Resident #2 was admitted [DATE] at 7:45 PM, with [DIAGNOSES REDACTED]. Resident #2 was transferred to an acute care facility on 1/25/13 at 10:48 PM. There were the following discrepancies regarding the orders and administration of the oxygen (02): There were no orders for the oxygen listed on the admission orders [REDACTED]>92%. The Intake/Output Vital Signs Record indicated oxygen at 3 LPM, and the nurse's notes indicated oxygen was administered at 4 LPM. There were the following discrepancies regarding the orders and administration of the SVN (small volume nebulizer) treatments. The admission orders [REDACTED]. The TAR did not list the SVN treatments to be given every 4 hours per the physician's orders [REDACTED]. The only documented administration on the TAR was at 1/25/13 at 6:00 AM. There was no documented evidence on the TAR of any other administration of the SVN Treatment every 4 hours as ordered by the physician. Review of the Nurse's Notes revealed the resident refused the SVN treatments. There was no documented evidence the facility made another attempt to administer the SVN treatment following the initial refusal. There was no documented evidence the physician was notified regarding the resident's refusal. -The following Nurse's Notes revealed Resident #2's oxygen saturation levels began to drop on 1/25/13 at 9:00 PM: "1/25/13 / 9:00 PM: Reported by LPN (licensed practical nurse), patient's 02 sat is 53% 4L/min via NC but fluctuating from 53% to 94%, goes up then down. Patient is a mouth breather, he is alert and oriented with periods of confusion at times. Pulse rate is 125 beats/min (minute), temp (temperature) 100.1, RR (respiratory rate)=32, BP (blood pressure=110/60. Distress noted. SVN PRN given by LPN. O2 sat fluctuates went up to 90's then down again to 50's. 1/25/13 / 9:20 PM: LPN gave anti-anxiety medication at this time. Remains on 02 4L min via NC. 1/25/13 / 10:10 PM: Still (with) SOB, 02 sat fluctuating, [MEDICAL CONDITION] Called Physician Assistant (with) orders EKG, SVN tx (treatment) again. 1/25/13 / 10:15 PM: SVN tx given as ordered. 1/25/13 / 10:30 PM: EKG done by LPN, showed sinus [MEDICAL CONDITION] 1/25/13 / 10:34 PM: Called Physician Assistant - Notified EKG (electrocardiogram) report - Sinus [MEDICAL CONDITION] Still with pulse of 125 beats/minute, in distress, 02 sat (with) 02 4L/min (illegible) at 86% but fluctuates, using accessory muscles, not in good condition (with) order send to (acute care facility) ER - Emergent for acute respiratory distress." The Daily Skilled Nurse's Note indicated: -1/25/13 / 6:00 AM - 6:00 PM: Pt alert & very confused. Refuses care & yells at staff, "Get out of here." -1/25/13 / 9:00 PM: Report given to RN (registered nurse) change of patient 02 sat. Mouth breather 02 4 L PM NC=54 when at rest (illegible). 02 sat 97%, medicated as ordered, remains on [MEDICATION NAME] po (by mouth), aspirations...will continue to monitor. -1/25/13 / 9:20 PM: Patient restless; [MEDICATION NAME] 0.25 mg po given. SVN tx (treatment) given as ordered A/A (Atrovent/[MEDICATION NAME]). -1/25/13 / 10:10 PM: RN Charge Nurse made aware of (increased) pulse and (decreased) 02 sat. Pulse=123 min (minute). 02 sat 54% 4LPM NC..." -The physician's orders [REDACTED]. Indication/DX (diagnosis): O2 sats low 53% (with) 02 4 L (O2 sats fluctuates), mouth breather, [MEDICAL CONDITION]" The physician's orders [REDACTED]." -The Physician's Transfer Summary indicated the SVN treatment was to be administered every 4 hours for shortness of breath. The Summary further indicated, "Hospital Course: Unfortunately, the very next day after being admitted here the patient was having respiratory distress. On-call provider was (name of Physician's Assistant) who gave the order to send the patient to (acute care facility) ER for respiratory distress. For further details on what happened, please refer to the nurse's notes..." Resident #2 was transferred to the acute care facility Emergency Department on 1/26/13 at 10:48 PM. The Physician's emergency room Report indicated, "Chief complaint: Dyspnea. This started today and is still present. It was gradual in onset and has been constant. The dyspnea is severe...(According to EMS (Emergency Medical Service) patient developed respiratory distress at 9pm tonight while resident at (name of skilled nursing facility)...Per rehab (rehabilitation) staff patient developed dyspnea, hot to touch and was 43% on 4L (liters) NC and was placed on 15 L NRB (Non Rebreather). Upon EMS arrival patient 02 sats 70% on NRS (NRB) 15L, RR (respiratory rate) 50's and with AMS (altered mental status)...EKG (Electric Cardio Gram):...Sinus [MEDICAL CONDITION] and Procedures: Pt (patient) presents with acute [MEDICAL CONDITION] and resp ([MEDICAL CONDITION]. Pt intubated PTA (Prior to Arrival) by EMS. Pt has supposed hx (history) of [DIAGNOSES REDACTED] and is alerted at baseline. Pt with fever probably pneumonia however no pneumonia on CXR (chest x-ray) or CT (Computerized Tomography)...pt not hypotensive and given resp (respiratory) failure probable [MEDICAL CONDITION]" On 4/2/13 at approximately 1:30 PM, chart review and interview was conducted with the DON, who verified the admission orders [REDACTED]. The DON further verified the TAR did not include the correct order for the SVN Treatments to be administered every 4 hours. The DON and the Charge Nurse (Employee #3) indicated the facility's policy when a resident refuses a medication or treatment, they re-approach the resident and try 3 times, and then contact the physician if the resident still refuses. On 4/3/13 at approximately 8:30 AM, chart review and an interview with Employee #4 (licensed practical nurse) and #5 (registered nurse) was conducted, and revealed the following: Employee #4 and #5 verified the oxygen order upon admission was 2 liters. Employee #4 indicated she did not get any report from the day shift nurse (Employee #6) regarding how many liters of oxygen Resident #2 was on, and stated, "When I saw him at 9:00 PM when we checked vital signs with sats (saturation levels) he was already on 4 liters." Employee #4 further indicated the resident was restless and anxious and appeared short of breath. Employee #4 and #5 verified the physician's orders [REDACTED]. Employee #4 indicated she did not know why the TAR had the SVN Treatments scheduled for only 4 times daily. Upon questioning how many times the sats went below 92%, Employee #4 indicated she could not remember, that the sats fluctuated. Employee #5 reviewed the TAR and verified the SVN treatment was administered on 1/24/13 at 10:00 PM, and that Resident #2 refused the SVN treatment on 1/25/13 at 2:00 AM. Employee #4 verified there was no documentation the sats were continuously monitored from 9:00 PM through 10:10 PM, and stated, "We can't do one-on-one". Employee #4 and #5 indicated a drop of sats to 53% constituted a significant change of condition. On 4/3/13 at approximately 10:00 AM, Employee #6 (LPN) was interviewed, and indicated she first administered the SVN treatment at 10:00 AM on 1/25/13, and verified that, according to the TAR's, the 10:00 AM dosage on 1/25/13 was the next treatment administered to the resident since admission (at 7:45 PM on 1/24/13). Employee #6 indicated the facility's policy if a resident refuses medication or treatment was, "After the first time of refusal of medication or treatments I notify the doctor." Employee #6 verified she did not re-approach the resident to offer the medications and treatments again, and that she did not contact the physician regarding the refusal of the SVN treatments. Employee #6 indicated that, normally when report is given to the nurse on the next shift, it does include the patient's status and condition, any significant changes, if the resident has refused medications, if a resident who is on oxygen is getting room air, SVN treatments, or oxygen. Policies and Procedures included, which indicated the following: -"Physician Communication/Change in Condition", revised 9/2011: "Procedures: 1. Complete assessment of the patient/resident which may include but is not limited to:...B. Current physical condition. C. Patient's/Resident's previous condition (declining, improving, stable). 2. Notify the physician of the change in medical condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's/resident's condition in the medical record... The Physician Communication Grid referred to above in Section 2 indicated Physician treatment required within 1 hour for new onset fever, shortness of breath (acute onset or with chest pain, change in VS (vital signs), labored breathing, 02 saturation < 95%); Vital Signs (respiratory rate > (more than) 30.)" The Physician Communication Grid further indicated, "These guidelines are not intended to substitute for good nursing judgement. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life-threatening event. The above applies 24 hours a day 7 days a week." -"Physician Orders", revised 9/2011: "Policy: The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines... Medication/Treatment: 2. Transcribe the order onto the Medication Administration Record (MAR) or Treatment Record as appropriate. Initial and date the entry on the the MAR/Treatment Record... -"Medication Management Program", revised 9/2011: "...3. Authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff must understand: D. The 'seven (7) Rights' for administering medication: 1) The Right Patient/Resident. 2) The Right Drug. 3) The Right Dose. 4) The Right Time. 5) The Right Route. 6) The Right Charting. 7) The Right Results'... 4. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member identifies that the following information, but not limited to, is documented on the MAR: A. Correct physician's orders [REDACTED]. 12. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member administers Inhalation medications as follows: M. The authorized licensed/certified staff member documents that the medication is given in the correct slot of MAR, before going to the next patient/resident. N. If the patient/resident is unable to take the medication or refuses it, the authorized licensed/certified staff members circles his/her initials on the MAR, and documents the reason refused or not given on the designated area of the MAR (physician is notified as necessary)..." -On 4/3/13 in the afternoon, the DON provided a reference manual (no title or date), Box 23-2: Oxygen Safety Guidelines, which indicated, "-Remind patients that oxygen is a medication and is not adjusted without a physician's orders [REDACTED]. -"Documentation - Licensed Nursing", revised 9/2011: "Procedures: The nursing staff will be responsible for recording care and treatment, observations, and assessments and other appropriate entries in the patient/resident clinical record according to state specific nurse practice acts... 4. Medications and Treatments: The qualified nursing staff notes the time, date and dosage of all medications and treatments at the time they are administered and initials the note on the medication and/or treatment record. The nurses's full name and title must be written at least once on each page of the Medication/Treatment Record or on an individual resident specific signature sheet. If a scheduled medication is withheld or not given as ordered, the nurse documents this and lists the reason for the patient/resident not receiving the medication... 8. Nursing Progress Notes/Other: A. Significant Change: A significant change in condition is noted in the nursing progress notes as soon as possible after observation of the patient/resident. Notification of the physician/family member and/or responsible party of such occurrences are also noted in the medical record..." The facility failed to ensure oxygen and SVN treatments were administered in accordance with physician's orders [REDACTED]. Complaint #NV 629

Based on observation, medical record review, interview and policy review the facility failed to: 1) ensure physician orders [REDACTED].#1 and #8 ); 2) follow physicians orders regarding the administration of oxygen for 3 of 9 residents with orders for oxygen (Resident #5, #6 and #7 ); and 3) ensure a physician's orders [REDACTED].#2 and #12). Findings include: Facility policy entitled "Physician Orders", revised 9/2011, read: "Policy: The qualified licensed nurse will obtain and transcribe orders according to Facility Practice Guidelines... Medication/Treatment: 2. Transcribe the order onto the Medication Administration Record (MAR) or Treatment Record as appropriate. Initial and date the entry on the the MAR/Treatment Record..." Facility document entitled "Medication Management Program", revised 9/2011, read: "...3. Authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff must understand: D. The 'seven (7) Rights' for administering medication: 1) The Right Patient/Resident. 2) The Right Drug. 3) The Right Dose. 4) The Right Time. 5) The Right Route. 6) The Right Charting. 7) The Right Results'... 4. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member identifies that the following information, but not limited to, is documented on the MAR: A. Correct physician's orders [REDACTED]. Facility Policy entitled, "Oxygen Therapy General Policy" Complete Revision: 6/2012 indicated: "...8. Start O2 flowrate at the prescribed liter flow or appropriate flow for administration device." Facility policy entitled, "Weaning From Supplemental Oxygen" Complete Revision": 6/2012 indicated: "Policy: Practitioners may systematically reduce and evaluate oxygen therapy when requested by the attending physician or by approved clinical protocol... Procedures: 6. All changes in... liter flow and the patient's/resident's tolerance of oxygen reduction must be documented on the ... treatment record. 7. All changes in oxygen flow rates ...must be documented as new physician's orders [REDACTED]. Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/14/13 at 9:25 AM, Resident #1 was observed lying in bed with eyes closed, with a nasal cannula (a narrow, flexible plastic tubing used to deliver oxygen) to the nose. The nasal cannula tubing was attached to an oxygen flow meter to the medical oxygen wall outlet. The oxygen flow meter was off. The black float rested at the bottom of the flow meter. On 8/14/13 at 9:27 AM, the Licensed Practical Nurse (LPN) Employee #3 confirmed Resident #1 was supposed to be on 2 liters of oxygen. At this time, the LPN walked into the resident's room with he inspector. The LPN turned the oxygen on to 2 liters per minute (LPM). The LPN proceeded to asked the resident, "Mr. NAME, are you short of breath? Are you okay?" On 8/14/13 at 9:45 AM, the Director of Nursing (DON) was made aware of Resident #1's oxygen observed to be off. At this time, the DON walked over the the LPN and asked why the resident's oxygen was off. The LPN responded, "I don't know." The DON asked the LPN to check the resident's O2 SATs (oxygen saturation -a measure of how much oxygen the blood is carrying). On 8/14/13 at 9:50 AM, review of Resident #1's medical record revealed the following: - history and physical examination [REDACTED]." - Medication Administration Record (MAR) from the previous SNF with hand written documentation dated 7/31/1. The MAR documented "Pt (patient) to receive O2 (oxygen) to maintain SPO2 (blood oxygen saturation) (>=) greater than or equal to 92%..." - admission orders [REDACTED]. - Care plans dated 8/6/13 - 8/14/13 lacked documented evidence of oxygen use. On 8/14/13 at 10:00 AM, the Registered Nurse (RN) Employee #4 reviewed Resident #1's medical record for an oxygen order. The RN could not locate an oxygen order in Resident #1's medical record. At this time, the RN identified the MAR in the the resident's medical record as a MAR from the previous SNF. The RN verbalized, "The resident was on O2 previously and it should have been transcribed to an order." On 8/14/13 at 11:25 AM, the DON indicated Resident #1's SATs were 94% in the morning and were at 95% when rechecked. The DON confirmed there was no order for oxygen. Resident #2 Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/14/13 at 10:20 AM, Resident #2 was observed seated in bed with a nasal cannula to the nose. The nasal cannula tubing attached to an oxygen flow meter to the medical oxygen wall outlet. The black float in the oxygen flow meter indicated the oxygen was at 3 LPMs. At this time Resident #2 indicated being at the facility for approximately one week. The resident verbalized, "I was at 1 1/2 liters. When did they put me up to 3 liters." On 8/14/13 in the morning, Resident #2's medical record revealed the following: - A physician telephone order dated 8/7/13 at 22:00 (10:00 PM) for "Oxygen @ (at) 2L via nasal cannula.(sic) - SOB (shortness of breath)." - A Treatment Record dated 8/7/13 with an order for [REDACTED]. The treatment record did not document any adjustments made regarding Resident#2's oxygen. - The Treatment Record for August 2013 documented on 8/14/13 for 6 a - 6 (6:00 AM - 6::00 PM) indicated a nurse's initials next to the entry for O2 2L/min (liters per min) via NC. The documented SATs were 95%. - Care plans dated 8/6/13 - 8/14/13 lacked documented evidence of oxygen use. On 8/14/13 at 12:00 PM, the LPN Employee #10 walked into the resident's room with the inspector. The LPN confirmed the resident's oxygen was at 3 liters. Art this time the LPN adjusted the resident's oxygen to 2 liters. Resident #2 verbalized, "I'm supposed to be at 2 liters." The LPN indicated the resident was confused at times. The LPN explained the O2 is 2 - 3 liters depending on the O2 SATs. The LPN indicated we titrated (adjust) per facility protocol. The LPN indicated if the O2 is above 3 liters the PA (physician assistant) or the physician is made aware and we get an order. On 8/14/13 at 2:45 PM, the DON confirmed a physician's orders [REDACTED]. The nurses can use their nursing judgment, but then the physician is notified. The DON verbalized, "This is a medication error." Resident #12 Resident #12 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/14/13 at 10:10 AM, Resident #12 was observed lying supine (on the back) in bed with a nasal cannula to the nose. The nasal cannula tubing attached to an oxygen flow meter to the medical oxygen wall outlet. The black float in the oxygen flow meter indicated the oxygen was at 1.5 LPMs. On 8/14/13 In the afternoon, Resident #12's medical record revealed the following: - A History and Physical dated 8/10/13, documented "O2 sat is 94 % on 2 liters. - admission orders [REDACTED]@ 2 LPM via NC. Keep SATs (>=) 92%. - The Treatment Record dated 8/10/13, documented on 8/14/13 for 6:00 AM - 6::00 PM indicated a nurse's initials next to the entry for O2 2 LPM via NC. Keep SATs (>=) 92%. The documented SATs were 98%. - A Comprehensive Care Plan dated 8/10/13, identified Resident #12 had O2 at 2L per NC. The approaches documented included "4. Apply O2 per order...". On 8/14/13 at 3:10 PM, the RN walked to the resident's room with the inspector. The RN confirmed the resident's O2 was at 1.5 LPM. The RN increased the resident's O2 to 2 liters. The RN verbalized, I might be the flow meter. The RN indicated the residnet had no order to titrate O2. Resident #5 Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/14/13 at 11:00 AM, review of Resident #5's medical record revealed an admission order dated 7/24/13, for oxygen 2 liters via nasal cannula. On 8/14/13 at 11:30 AM, Resident #5 was lying in a bed on room [ROOM NUMBER]. The resident was observed wearing an oxygen nasal cannula that was connected to an oxygen concentrator (a device providing oxygen therapy). The concentrator was inspected with Employee #6. The employee verified the concentrator was properly functioning and dispensing 3.5 liters of oxygen per minute. Employee #6 could not explain why Resident #5 was receiving 3.5 liters of oxygen per minute instead 2 liters per physician's orders [REDACTED]. Review of Resident #5's record revealed the medical administration record (MAR) did not document the order for oxygen. The record lacked documented evidence an order for [REDACTED]. The facility failed to ensure oxygen was administered in accordance with physician's orders [REDACTED]. Resident #6 Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/14/13 at 10:55 AM, Resident #6 was lying in a bed on room [ROOM NUMBER]. The resident was not receiving oxygen. There was not observed oxygen tank or oxygen concentrator in the room. During the inspection, it was noted room [ROOM NUMBER] lacked oxygen wall outlets. On 8/14/13 at 11:00 AM, Employee #6 obtained Resident #6 oxygen saturation (oxygen saturation refers to the extent to which blood is saturated with oxygen) using a pulse oxymeter device. The oxygen saturation was 95 % . The employee explained Resident #6 should be receiving oxygen as needed per physician ordered. Review of Resident #6 MAR for August 2013, revealed an order that read: "...O2 (oxygen) at 2 LPM (liters per minute) via nasal cannula to keep O2 sat (oxygen saturation) ? (more or equal than) 92 % PRN (Latin phrase "Pro Re Nata" which translates as "as the thing is needed")". The MAR documented oxygen was administered from 8/11/13 to 8/14/13. On 8/14/13 at 11:20 AM, review of Resident #6's medical record revealed a physician admission order dated 4/13/13 that read: "...O2 at 2 LPM via nasal cannula continuous to keep O2 sat > (more than) 92 % (percent)". The physician order [REDACTED].#6 mentioned. Review of the facility unit 2 Vital Sign Log indicated Resident #6's Oxygen saturation was 91 % on 8/13/13 in the morning. There was not documented evidence in Resident #6's record the oxygen was administered and the oxygen saturation was re-checked. Resident #6's record lacked documented evidence a care plan for the administration of oxygen was initiated. The facility failed to ensure oxygen was administered to Resident #6 in accordance with physician's orders [REDACTED]. The MAR indicated the resident received oxygen when it was not administered. Resident #7 Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/14/13 at 10:55 AM, Resident #7 was lying in a bed on room [ROOM NUMBER]. The resident was not receiving oxygen. There was not observed oxygen tank or oxygen concentrator in the room. On 8/14/13 at 11:15 AM, Employee #7 obtained Resident #6 oxygen saturation using a pulse oxymeter device. The oxygen saturation was 96 %. The employee explained Resident #7 should be receiving oxygen per physician ordered. On 8/14/13 at 11:34 AM, review of Resident #7's medical record revealed a physician admission order dated 7/9/13 that read: "...O2 @ (at) 2 L (liters) via NC (nasal cannula) to keep sats ? 92 %". Resident #7's medical record lacked documented evidence the order for oxygen was transcribed to the MAR and a care plan for the administration of oxygen was initiated. The facility failed to follow physician orders [REDACTED].#7. Resident #8 Resident #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 8/14/13 at 2:00 PM, Resident #8 was lying in a bed on room [ROOM NUMBER]. The resident was observed wearing an oxygen nasal cannula that was connected to an oxygen concentrator. The concentrator was inspected with Employee #9. The employee verified the concentrator was properly functioning and dispensing 2 liters of oxygen per minute. On 8/14/13 at 2:10 PM, review of Resident #8's medical record revealed there was not order for the administration of oxygen. On 8/14/13 at 2:30 PM, Resident #8's record was reviewed with the charge nurse Registered Nurse (RN) Employee #7 and Clinical Director Licensed Practical Nurse (LPN) Employee #8. The employees could not find a physician order [REDACTED].#8. The RN Employee #7 expressed the physician would be notified to obtain an order. The employee explained oxygen at 2 liters did not need a physician order. Resident #8's record lacked documented evidence a physician order [REDACTED]. The facility failed to ensure the oxygen was administered after obtaining a physician order.

Based on record review, documentation review, and interview, the facility failed to ensure a resident having a pressure ulcer received necessary treatment to promote healing through: 1) notifying the physician of wound condition changes; 2) implementing preventive interventions in a timely manner; and 3) reviewing and revising the pressure ulcer care plan (Resident #2). Findings include: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 7/23/10, documentation related to the resident's coccyx pressure ulcer read as follows on the Wound Care Progress Notes form: "coccyx pressure ulcer Stage 1, 5 cm (centimeters) x 10 cm; red D/I (dry and intact) nonblanchable with pink periwound. labs reviewed. Dr.___, aware, new orders received." A care plan for Resident #2 was created on 7/23/10, with the identified Problem as "Pressure area: Stage 1 coccyx." The goal was written as "skin will remain clean and dry and area will heal over the next 90 days. The following approaches were included in the care plan: "perform treatment per order; keep family/responsible party and MD informed of resident's progress." On 7/25/10 Wound Care Progress Notes read, "coccyx pressure ulcer Stage 2, 5 cm x 10 cm; superficial, open, 100% red, nonblanchable. Dr.__ aware." These progress notes were transcribed onto a Weekly Wound Tracking Worksheet. The Director of Wound Care (Employee #5) explained that the Weekly Wound Tracking Worksheet was a tool utilized by the facility for physicians to receive updates of the status of residents' wounds. However, there was no documented evidence in the record (including physician progress notes [REDACTED]. changed and was now an open Stage 2 pressure ulcer. In an interview with one of the facility's Physician Assistants (PAC #1) on 11/2/10 at 1:30 PM, the PAC reported that the facility's PACs and physicians did not use the Weekly Wound Tracking Worksheet as a tool to obtain information about changes in residents' wound conditions. The PACs/physicians instead relied on the Wound Care Team to verbally tell them about any changes. PAC #1 acknowledged that whenever this communication occurred between the Wound Care Team and a PAC, it was not normally documented in the resident's record. According to the facility's "Wound Care Policies and Procedures" policy, dated 10/2009, "Abnormal findings/changes should be reported to the resident's primary care provider and family/responsible party by the licensed nurse per facility protocol. Documentation of the primary care provider notification, orders received, family notification, and resident response to any treatment should follow facility as well." The 8/7/10 Wound Care Progress Notes read, "Coccyx pressure ulcer D/I, 8 cm x 12.4 cm, 60 % deep purple, 40 % red nonblanchable base, purple periwound, min (minimum) serous drainage. (PAC) aware; new orders received. Low air loss mattress." (The resident received a low air loss mattress on 8/18/10, eleven days after the order.) Review of physician orders [REDACTED]." This order was written on the August Wound Treatment and Progress Record, but there was no evidence the order was being carried out by the Wound Care Team until 8/21/10, when the treatment was initialed each day from 8/21/10 to 8/31/10. Employee #5 and the Acting DON (Director of Nursing) (Employee #6) could not provide evidence that this treatment order was carried out from 8/7/10 through 8/20/10. Wound Progress Notes, dated 8/8/10, read as follows: "Coccyx pressure ulcer, unstageable, 11 cm x 10 cm, 50 % black, 30 % red base, 20 % purple tissue, moist, min serous drainage, periwound pink." On 8/15/10, the description of the coccyx pressure ulcer on the Wound Progress Notes read, "Stage 2, 6.5 cm x 9 cm, 40 % red base, 30 % yellow slough, 30 % brown eschar, moderate serous sanguinous drainage, periwound purple." The facility's "Staging of Pressure Ulcers - National Pressure Ulcer Advisor Panel - NPUAP," dated 10/2009, listed definitions of pressure ulcer definitions. According to the policy, a Stage 2 ulcer has "partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister." A Stage 3 ulcer was defined as "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." A Stage 4 pressure ulcer has "full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling." An "Unstageable" ulcer is defined as "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined....For MDS (minimum data set) coding, eschar covered wounds are coded as Stage 4." According to these definitions, Resident #2's coccyx pressure ulcer on 8/15/10, with evidence of slough and eschar, should have been staged at Stage 3 or Stage 4. There was no documented evidence the physician and family members were informed about the change of condition of the wound. The PAC indicated that PACs should be notified if a wound begins to show evidence of slough or eschar. The facility's "Pressure Ulcers" policy, dated 10/2009, included the following procedures: "Re-evaluate pressure ulcers at least weekly. If the resident's condition, or the condition of the wound deteriorates, or if there is no significant progress within a reasonable time frame, the treatment plan should be re-evaluated. If the treatment plan is not changed, documentation should be provided as to why the current treatment plan is being maintained." There was no evidence in the record that the resident's treatment plan was re-evaluated, in conjunction with the PAC, when the pressure ulcer exhibited slough and eschar. The 8/22/10 Wound Progress Notes included the following description: "Coccyx pressure ulcer, Stage 2, 6 cm x 8.4 cm, 50 % moist red base, 50 % yellow slough, pink macerated periwound." The 08/29/10 description on the Wound Progress Notes read, "Coccyx pressure ulcer, Stage 2, 5.3 cm x 8.3 cm x 0.3 cm, moist, 40 % yellow slough, 60% red base, periwound red, scant serosanguinous drainage." There was no documented evidence of physician notification, when the ulcer developed a depth dimension. On 9/12/10 Wound Progress Notes were, "Coccyx pressure ulcer, Stage 4, 5.3 cm x 7.8 cm x 1.4 cm, 30 % yellow slough, 60 % red base, 10 % red tissue moist, min serous drainage, periwound pink." The facility's "Wound Evaluations" policy, dated 10/2009, outlined the following: "Evaluation of wounds will be performed on admission, weekly, and on discovery...Evaluation results are communicated to the members of the care team through documentation, case conference, and care planning." A review of Resident #2's Pressure Ulcer care plan revealed it was never updated after 7/23/10. There was no evidence that wound care audits were being conducted by the Director of Wound Care with regard to those he supervised, or by the facility through a performance improvement process. Audit forms were available in the facility, but they were not being used, and this was confirmed by both Employees #5 and #6. According to the facility's "Wound Care Policies and Procedures - Reference" policy, dated 10/2009, "Evaluation of in-house acquired pressure ulcers should be ongoing as part of the quality assurance/process improvement process with management of the pressure ulcers occurring daily in accordance with primary care provider orders/nursing interventions and information reviewed on a weekly, monthly, and quarterly basis to assist in identifying trends, management, validation that interventions are in place, and a process for monitoring sustained improvement and effectiveness." Facility's Corrective Action: The facility's correction action was to: 1) implement weekly audits of all wound care treatments; 2) ensure PACs/physicians are aware of any wound condition changes, through accurate/consistent Staging definitions by the wound care team and documentation of this notification in residents' clinical records; 3) ensure air mattresses are provided as ordered in a timely manner; 4) ensure pressure ulcer care plans are reviewed and revised with changes in wound conditions; and 5) track, monitor, and evaluate wound care as an ongoing part of the facility's performance improvement process. No POC (plan of correction) response is required for this tag.