Every finding on record at Royal Springs Healthcare and Rehab

Based on interview and document review, the facility failed to ensure annual dementia training was provided to 3 of 11 employees reviewed (Employee 1, 2 and 13). The deficient practice placed residents with dementia at risk for receiving inappropriate care. Findings include:The Facility Assessment, dated 02/2026, documented training for care management for persons with dementia would occur upon hire and annually.On 03/13/2026 at 7:50 AM, the Director of Staff Development (DSD) explained annual trainings were scheduled and tracked to ensure completion.On 03/13/2026 at 7:57 AM, personnel records revealed Employee 1, 2, and 13 had not completed annual dementia training.Employee 1 was hired on 08/17/2021 as the Administrator. The Administrator completed dementia training on 01/27/2025.Employee 2 was hired on 09/14/2001 as the Director of Nursing (DON). The DON completed dementia training on 01/27/2025.Employee 13 was hired on 10/30/2019 as the Infection Preventionist (IP). The IP completed dementia training on 01/09/2025.On 03/13/2026 at 8:12 AM, the DSD confirmed Employees 1,2, and 13 had not completed the annual dementia training. The DSD explained the training was expected to be completed annually and staff needed to be aware of the need to complete required training.On 03/13/2026 at 11:30 AM, the Administrator explained the expectation was for dementia training to be completed timely and completed annually. The facility policy titled Dementia Training, revised 03/2026, documented all facility employees must complete at least three hours of continuing education in dementia care annually.

Based on observation, interview, record review, and document review, the facility failed to develop and implement a comprehensive care plan for the use of an electronic communication device (a camera) for audio and video recording for 1 of 40 sampled residents (Resident 7). The deficient practice placed residents, staff, and visitors at risk for violations of privacy, dignity, and confidentiality.Findings include:Resident 7 (R7) was admitted [DATE], readmitted [DATE], with diagnosis including acute respiratory failure with hypoxia, other symptoms and signs involving cognitive functions following cerebral infarction, and chronic pain syndrome.On 03/10/2026 in the morning, R7 was observed lying in bed with eyes open, with their body in a contorted position. A camera was installed on the wall opposite R7's bed, positioned above eye level. A posted sign indicated an electronic communication device was in use and may record audio and or video at all times. A roommate was present in R7's room. On 03/11/2026 at 1:43 PM, the Director of Nursing, DON explained R7's family was involved in R7's care and requested a camera be installed in R7's room. The DON confirmed a camera was present in R7's room and was actively recording audio and video. The DON stated R7's family continuously monitored the audio and video from the camera.An Interdisciplinary Care Plan Conference dated 09/30/2024, documented a care conference was held regarding the installation of a monitoring device in the shared resident room in accordance with the law.A Care Plan dated 02/10/2026 lacked documented evidence a care plan was developed for the use of the camera. On 03/11/2026 at 3:30 PM, the Director of Nursing (DON), confirmed R7's care plan lacked documented evidence a care plan had been developed for the use of the camera.A facility policy titled Care Plans, Comprehensive Person-Centered Revised December 2016 documented the Interdisciplinary Team, in conjunction with the resident and the family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.Resident 7 (R7)R7 was admitted [DATE], readmitted [DATE], with diagnosis including acute respiratory failure with hypoxia, other symptoms and signs involving cognitive functions following cerebral infarction, and chronic pain syndrome.On 03/10/2026 in the morning, R7 was observed lying in bed with eyes open, with the body in a contorted position. A [NAME] was observed installed on the wall opposite the R7's bed, positioned above eye level. A posted sign indicated an electronic communication device was in use in the room and may record audio and or video at all times. A roommate was present in R7's room. 03/11/2026 at 1:43 PM, the Director of Nursing, DON explained R7's family was involved in R7's care and requested a [NAME] be installed in R7's room. The DON confirmed a [NAME] was present in R7's room and was actively recording audio and video. The DON stated R7's family continuously monitored the audio and video from the [NAME]. An Interdisciplinary Care Plan Conference dated 09/30/2024, documented a care conference was held regarding the installation of a monitoring device in the shared resident room in accordance with the law. A Care Plan dated 02/10/2026 lacked documented evidence a care plan was developed for the use of the electronic communication device ([NAME]). On 03/11/2026 at 3:30 PM, the Director of Nursing (DON), confirmed R7's care plan lacked documented evidence a care plan had been developed for the use of the electronic communication device ([NAME]). The DON acknowledged a care plan should have been developed for the [NAME] to ensure staff awareness of recording, including the development of goals and interventions, such as the need for signage to be posted.A facility policy titled Care Plans, Comprehensive Person-Centered Revised December 2016 documented the Interdisciplinary Team, in conjunction with the resident and the family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

Based on observation, interview, record review and document review, the facility failed to revise the comprehensive care plan when modifications were made to a resident's nephrostomy tube for 1 of 40 sampled residents (Resident 29) and when a resident returned from the hospital under hospice care with a change in code status for 1 of 40 sampled residents (Resident 227). The deficient practice had the potential to negatively impact on the quality of care the residents received.Findings include: Resident 29 (R29) was admitted on [DATE] and readmitted on [DATE], with diagnoses including hydronephrosis with renal and ureteral calculus obstruction, encounter to nephrostomy and other artificial openings of urinary tract.A care plan initiated 02/15/2025, revealed R29 was admitted with bilateral nephrostomy tubes with a goal of having no signs and symptoms of infection by checking tubing for kinks, monitoring and recording output, monitoring discomfort and notifying physician if no urine output.A hospital Discharge summary dated [DATE], revealed R29 was admitted with bilateral nephrostomy tubes and the left nephrostomy tube was exchanged with a stent by interventional radiology. R29 to return to skilled nursing facility with a right-sided nephrostomy tube. The medical record lacked documented evidence R29's care plan was updated to reflect removal of left nephrostomy tube.On 03/11/2026 at 2:52 PM, the Unit Manager indicated R29's care plan for nephrostomy was not updated when R29 returned with only one nephrostomy tube. The Unit Manager indicated this would have been a good time to review R29's care plan to identify and include interventions which were lacking such as cleansing site with normal saline and changing dressing every one to three days per facility policy.Resident 227 (R227) was admitted on [DATE] and readmitted on [DATE], with diagnoses including malignant neoplasm of the bronchus or lung. A physician's order for life-sustaining treatment (POLST) dated 12/19/2025, revealed R227 did not have decisional capacity and a family member elected full code or attempt resuscitation in the event of cardiopulmonary arrest.A History and Physical dated 01/01/2026, revealed R227 returned to the facility on [DATE] following hospitalization for acute chronic hypoxic respiratory failure. The physician previously discussed hospice which the resident and family declined. After being medically stabilized at the hospital, R227 returned to the skilled nursing facility under hospice care.A hospice do not resuscitate (DNR) election form dated 12/29/2025, revealed R227's family member agreed to allow natural death do not perform medical procedure to try to restart heart.The medical record lacked documented evidence R227's comprehensive care plan was updated to reflect R227's hospice status and R227's change in code status.On 03/13/2026 at 11:06 AM, the Director of Nursing (DON) confirmed R227's comprehensive care plan was not updated to reflect changes in the resident's condition specifically code status from full code to DNR and hospice election while at hospital. The facility's Comprehensive Person-Centered Care Plan policy revised December 2016 revealed assessments of residents were ongoing and care plans were revised as information regarding the residents and the residents' condition changed.Complaint 272374

Based on observation, interview, record review and document review, the facility failed to ensure documentation of care pertaining to a nephrostomy catheter site, suprapubic catheter site and Foley catheter site were factual and aligned with actual care provided for 1 of 40 sampled residents (Resident 29). The deficient practice placed residents at risk for receiving substandard quality of care.Findings include:Resident 29 (R29) was admitted on [DATE] and readmitted on [DATE], with diagnoses including hydronephrosis with renal and ureteral calculus obstruction, encounter to nephrostomy catheter and other artificial openings of urinary tract.On 03/11/2026 at 9:40 AM, a licensed practical nurse (LPN) lifted R29's gown which revealed R29 had a suprapubic catheter (a thin, indwelling tube inserted through the lower abdomen into the bladder to drain urine) on left lower quadrant of the abdomen. The LPN used fingers to open abdominal fold and described the insertion site as not clean, had white build up, and no dressing. R29 was asked when the last time a staff member cleaned the catheter site. R29 responded, Never. No one comes to clean it!On 03/11/2026 at 9:43 AM, a certified nursing assistant (CNA) pulled R29's gown from behind which revealed a right-sided nephrostomy site covered in dressing dated 03/03. The CNA and LPN described the dressing as appearing old, coming loose having a brown stain at the center which maybe blood or Betadine. R29 was asked the last time staff provided care to the nephrostomy. R29 responded, no one comes. The LPN attempted to remove the dressing to assess the site, but it was stuck to the site and difficult to remove. The LPN indicated needing to get supplies to change the dressing.A physician order dated 02/10/2026, documented to cleanse suprapubic catheter with soap and water every shift.A physician order dated 02/10/2026, documented to cleanse nephrostomy tube catheter site with soap and water every shift.A physician order dated 02/10/2026, documented to cleanse Foley catheter site with soap and water every shift.The medication administration record (MAR) for March 2026, revealed staff signed off on cleansing R29's nephrostomy site, suprapubic catheter site and Foley catheter site with soap and water every shift. On 03/11/2026 at 10:00 AM, the LPN reviewed R29's MAR for March 2026 and confirmed the LPN had signed off on cleansing tasks for R29's nephrostomy, suprapubic and Foley catheter site with soap and water every shift without performing the tasks on 03/03/2026, 03/04/2026, 03/05/2026, 03/10/2026 and 03/11/2026. The LPN indicated not being aware of dressing change protocols for suprapubic catheters and nephrostomy tubes. The LPN confirmed R29 did not have a Foley catheter.On 03/11/2026 at 10:11 AM, the CNA steadily assigned to R29 indicated not being responsible for cleansing of R29's nephrostomy and suprapubic catheter insertion site because it was the duty of the nurse since it was the expectation the nurses would assess the site during the task.On 03/11/2026 at 10:29 AM, the Unit Manager indicated it appeared the MAR was signed off mechanically since R29 did not have a Foley catheter and the LPN had already admitted signing off on cleansing tasks for R29's nephrostomy and suprapubic catheter site without performing the care.On 03/11/2026 at 1:25 PM, the Director of Nursing (DON) indicated nephrostomy site care should be done daily. The DON indicated when a resident was admitted with a nephrostomy the admitting nurse must enter care orders to include cleansing of the site and dressing change to reflect time of last care.On 03/11/2026 at 1:27 PM, the DON indicated suprapubic catheter site should be assessed and cleaned with soap and water daily. The DON indicated nurses should not have been signing for cleansing tasks which were confirmed to have not been performed as this was a disservice to the residents who were placed at a higher risk for recurrent UTI.On 03/11/2026 at 1:29 PM, the DON indicated nurses who signed off on Foley care were not paying attention and this reflected mechanical documentation since R29 did not even have a Foley catheter.The facility's Documentation Standards of Nursing Practice (undated), documented Center for Medicare and Medicaid Services (CMS) standards and guidelines for MAR charting stated documentation must be accurate, truthful, comprehensive, timely and aligned with actual care provided. Accuracy of documentation ensured safe patient outcomes.

Based on interview, record review, and document review, the facility failed to ensure physician orders coincided with the documented treatment preferences as indicated on the Physician Order for Life Sustaining Treatment (POLST) form for 1 of 40 sampled residents, (Resident 32). The deficient practice had the potential for residents to receive medical interventions inconsistent with expressed wishes regarding life sustaining treatment. Findings include: Resident 32 (R32) was admitted on [DATE] with diagnoses including unspecified dementia with psychotic disturbance, Alzheimer's disease, and chronic kidney disease. A physician order dated 03/27/2025 documented Do Not Resuscitate (DNR). The POLST dated 09/07/2025 documented R32 was a Full Code, resident lacks decisional capacity. The POLST was signed by the physician and R32's family member. On 03/11/2026 at 10:50 AM, a Unit Manager explained the process for obtaining a resident code status was to explain Full Code versus DNR if resident was alert, if the resident was not alert the staff contacted the resident's representative. Once code status was verified a physician order would be entered and the POLST form filled out for the physician to sign. During an event requiring life sustaining treatment staff would obtain the POLST to confirm the resident's code status.The Unit Manager reviewed R32's POLST and physician orders and confirmed documented treatment preferences did not match. The Unit Manager explained the POLST and Physician orders needed to match. The Unit Manger was unable to determine R32's correct code status based on the conflicting orders. On 03/12/2026 at 9:35 AM, the Director of Social Services (SSD) explained the role of the social services for verifying advance directives and code status was to discuss with resident, responsible party, or Power of Attorney (POA) every three months regarding resident life sustaining treatment wish to ensure if any changes needed to be made. The SSD explained R32's family was responsible for making decisions. The SSD was unaware of any changes made to R32's code status. The SSD reviewed R32's medical record and confirmed no documented evidence of any conversation with family regarding code status since admission on [DATE]. On 03/12/2026 at 10:53 AM, the Director or Nursing (DON) explained the POLST was part of the admission packet and completed upon admission and a physician's order was to correspond with the POLST.

Based on observation, interview, record review and document review, the facility failed to ensure admission care orders which were transcribed into the medical record for a resident's nephrostomy tube, suprapubic catheter and Foley catheter were accurate, complete and were in accordance with facility policy and documented care for the resident's nephrostomy tube and suprapubic catheter aligned with actual care provided for 1 of 40 sampled residents (Resident 29). The deficient practice placed the resident at risk for recurrent urinary tract infection (UTI).Findings include: Resident 29 (R29) was admitted on [DATE] and readmitted on [DATE], with diagnoses including hydronephrosis with renal and ureteral calculus obstruction, encounter to nephrostomy catheter and other artificial openings of urinary tract.On 03/11/2026 at 9:35 AM, R29 laid alert in specialty bed and permitted a surveyor to be present for site assessment of their suprapubic catheter and nephrostomy tube. The Licensed Practical Nurse (LPN) assigned to R29 stood on left side of the bed while a certified nursing assistant (CNA) stood on right side of the bed. On 03/11/2026 at 9:40 AM, the LPN liftedR29's gown which revealed R29 did not have a Foley catheter but rather a suprapubic catheter (a thin, indwelling tube inserted through the lower abdomen into the bladder to drain urine) on left lower quadrant of the abdomen. The LPN used fingers to open abdominal fold and described the insertion site as not clean, had white build up, and no dressing. R29 was asked when a staff member cleaned the catheter site, R29 responded, Never. No one comes to clean it The LPN described the urine which was draining into the bag to be yellow with sediments.On 03/11/2026 at 9:43 AM, the CNA pulled R29's gown from behind which revealed a right-sided nephrostomy site covered in dressing dated 03/03. The CNA and LPN described the dressing as appearing old, coming loose having a brown stain at the center which could either be old blood or Betadine. R29 was asked the last time staff provided care to the nephrostomy. R29 responded, no one comes. The LPN attempted to remove the dressing to assess the site, but it was stuck to the site and difficult to remove. The LPN indicated needing to get supplies to change the dressing. The CNA indicated not being assigned to R29 and could not speak to care of the resident's suprapubic catheter and nephrostomy.The admission minimum data set (MDS) dated [DATE], documented R29 was admitted with an indwelling catheter (including suprapubic catheter and nephrostomy tube) and active diagnoses including renal insufficiency, obstructive uropathy and urinary tract infection (UTI) in the last 30 days.A physician order dated 02/10/2026, documented to cleanse suprapubic catheter with soap and water every shift.A physician order dated 02/10/2026, documented to cleanse nephrostomy tube catheter site with soap and water every shift.A physician order dated 02/10/2026, documented to cleanse Foley catheter site with soap and water every shift. The medical record lacked documented evidence orders for dressing change were entered or carried out for R29's nephrostomy tube and suprapubic catheter.The medication administration record (MAR) for March 2026, revealed staff signed off on cleansing of R29's nephrostomy site, suprapubic catheter site and non-existent Foley catheter site with soap and water every shift. On 03/11/2026 at 10:00 AM, the LPN reviewed R29's MAR for March 2026 and confirmed the LPN had signed off on cleansing tasks for R29's nephrostomy and suprapubic catheter site with soap and water every shift without performing the tasks on 03/03/2026, 03/04/2026, 03/05/2026, 03/10/2026 and 03/11/2026. The LPN indicated not being aware of dressing change protocols for suprapubic catheters and nephrostomy tubes. The LPN acknowledged signing off for Foley catheter site care when R29 did not have a Foley catheter. On 03/11/2026 at 10:11 AM, the CNA steadily assigned to R29 indicated not being responsible for cleansing of R29's nephrostomy and suprapubic catheter insertion site because it was the duty of the nurse since it was the expectation the nurses assess the site during the task.On 03/11/2026 at 10:29 AM, the Unit Manager reviewed R29's medical record and confirmed orders for dressing changes for R29's nephrostomy and suprapubic catheter sites were not entered and were required to reflect time of last care. The Unit Manager indicated it appeared the MAR was signed off mechanically since R29 did not have a Foley catheter and the LPN had already admitted signing off cleansing tasks for R29's nephrostomy and suprapubic catheter site.On 03/11/2026 at 1:25 PM, the Director of Nursing (DON) indicated nephrostomy site care should be done daily. The DON indicated when a resident was admitted with a nephrostomy the admitting nurse must enter care orders to include cleansing of the site and dressing change to reflect time of last care. On 03/11/2026 at 1:27 PM, the DON indicated suprapubic catheter site should be assessed and cleaned with soap and water daily. The DON indicated nurses should not have been signing for cleansing tasks which was confirmed to have not been performed as this was a disservice to the resident who was placed at a higher risk for recurrent UTI.On 03/11/2026 at 1:29 PM, the DON indicated nurses who were signing off on Foley care reflected mechanical documentation since R29 did not even have a Foley catheter.The facility's Care of Nephrostomy Tube policy revised October 2010 documented the purpose of the policy was to provide guidelines for care of percutaneous nephrostomy tube. Verifying a physician's order was in place for the procedure. Review the resident's care plan to assess any special needs for the resident. Change dressing every one to three days, observe for skin breakdown, infection or drainage. Place sterile drain dressings and secure with adhesive tape. Document date and time procedure was performed, resident response, any assessment data, to report abnormal findings.The facility's Use of Indwelling Catheter policy revised September 2010 revealed routine meatal (the urethral opening or surrounding area of an indwelling catheter) care was performed with soap and water on a daily basis and as needed.

Based on observation, interview, record review and document review, the facility failed to ensure head of bed (HOB) was elevated during tube feeding infusion in accordance with the facility policy for 2 of 40 sampled residents (Resident 53 and 176). The deficient practice placed residents receiving tube feeding at risk for aspiration.Findings include:Resident 53 (R53) was admitted [DATE], with diagnoses including nontraumatic intracranial hemorrhage and gastrostomy status. The quarterly minimum data set (MDS) dated [DATE], revealed R53 had moderately impaired cognition and was receiving nutritional by enteral means. On 03/10/2026 at 9:39 AM, R53 laid awake in low bed with Jevity 1.2 infusing by tube feeding pump at 80 milliliters per hour (ml/per). R53's HOB appeared flat to approximately 10 degrees. On 03/10/2026 at 9:47 AM, a charge nurse entered R53's room and confirmed tube feeding was running and would be turned off at 10:00 AM. The charge nurse confirmed R53's HOB was flat up to approximately 10 degrees. On 03/11/2026 at 9:22 AM, R53 laid in bed awake while tube feeding was infusing at 80 cc/hr. R53's HOB was elevated approximately 15 to 20 degrees. On 03/11/2026 at 9:24 AM, a Licensed Practical Nurse assigned to R53 confirmed R53's HOB was less than 30 degrees. On 03/13/2026 at 9:25 AM, a Certified Nursing Assistant (CNA) assigned to R53 entered the room with this surveyor. R53's tube feeding was infusing at 80 ml/hr; the CNA described R53's HOB as flat. On 03/13/2026 at 9:38 AM, the Unit Manager indicated the facility protocol was to keep HOB between 30 to 45 degrees during tube feeding infusion and up to one hour after to prevent aspiration. Resident 176 (R176) was admitted [DATE], readmitted [DATE], with diagnosis including cerebral palsy, dependence on respirator (ventilator status), and dysphagia oropharyngeal phase. On 03/10/2026 at 8:30 AM, R176 was lying in bed with eyes closed, with the torso and face turned toward the right in a contorted position. R176's head of the bed (HOB) was observed in a flat position (not elevated), while the enteral feeding pump was running with Jevity 1.2 (a feeding formula) at a rate of 65 milliliters per hour. A Care Plan dated 01/29/2026, documented R176 required tube feeding related to dysphagia. Goals included R176 would remain free of aspiration, side effects, and complications related to tube feeding. Interventions included maintaining the head of the bed elevated at 30 to 45 degrees during enteral feeding and for 30 minutes after feeding. A physician order dated 04/18/2025, documented to elevate HOB 30 to 45 degrees during and one hour after feeding. On 03/10/2026 at 8:37 AM, a Registered Nurse (RN), confirmed R176's HOB was flat while the enteral feeding pump was running. The RN reported the HOB was lowered to help R176 sleep. The RN explained the HOB should not have been flat during enteral feeding and should have been maintained at 45 degrees. The RN acknowledged R176 should not have been left in a flat position at any time during feeding to prevent aspiration and vomiting. On 03/11/2026 at 1:43 PM, the Director of Nursing (DON), confirmed the HOB should have been maintained elevated at a minimum of 30 degrees during enteral feeding and for 1 hour after feeding to prevent aspiration. The DON explained if a resident had been identified to benefit from a lower degree of HOB elevation, a new physician order and corresponding care plan update would have been required. A facility policy titled Enteral Feedings-Safety Precautions, revised November 2018, documented to elevate the HOB at least 30 degrees during tube feeding and at least one hour after feeding. If elevating the HOB was medically contraindicated, use the reverse Trendelenburg position.

Based on observation, interview, record review and document review, the facility failed to ensure psychotropic medication and opioid side effects were monitored for 2 of 40 sampled residents (Residents 7 and 64). The deficient practice had the potential to place residents at risk for experiencing adverse effects of medications. Findings include: Resident 64 (R64) was admitted on [DATE] with diagnoses including cerebral infarction, atherosclerotic heart disease of native coronary artery, and chronic obstructive pulmonary disease. On 03/10/2026 at 10:10 AM, R64 was lying supine in bed, eyes fluttering when spoken to, unable to stay awake and head dropping to the left side. On 03/10/2026 at 11:51 AM, a Certified Nurse Assistant (CNA) attempted to wake R64 and verbally encouraged R64 to wake up for food consumption. R64 was lying in bed with eyes closed, not eating. R64 responded to name being spoken by opening eyes and closed eyes again. A care plan dated 02/21/2026 documented R64 had insomnia related to altered sleep pattern as evidenced by need for sleep aid Trazodone. Interventions included to monitor side effects such as daytime drowsiness, dizziness, and orthostatic hypotension. A physician order dated 11/22/2025 documented Trazodone Hydrochloride Tablet 50 MG, give one tablet by mouth at bedtime for insomnia. R64's medical record lacked the monitoring of side effects and hours of sleep for Trazadone. On 03/11/2026 at 10:15 AM, R64 was lying in bed with eyes closed, not responding to knock on the door or call of name. On 03/11/2026 at 10:30 AM, a CNA explained R64 liked to sleep most of the day. On 03/11/2026 at 10:36 AM, a Registered Nurse (RN) explained R64 was sometimes confused with day and night when awakened to take morning medications. The RN explained with medications administered for sleep, the side effects would be monitored and documented on the Medication Administration Record (MAR). The RN reviewed R64's medical record for Trazadone and confirmed R64 had no documented monitoring of side effects. On 03/11/2026 at 10:42 AM, the Unit Manager (UM) explained side effect monitoring was to occur daily and documented on the resident MAR. The UM reviewed R64's medical record and confirmed R64 lacked a physician's order for the monitoring of side effects. Staff had not documented daily monitoring of side effects was completed. On 03/12/2026 at 10:58 AM, the Director of Nursing (DON) explained the expectation for psychotropic medications was for staff to monitor side effects, record findings on MAR, and report to the physician as needed. The DON was unaware staff had not been monitoring for potential side effects of R64's Trazadone use. The DON confirmed excessive sleeping during the day would be a potential side effect of the medication that would need to be assessed. The facility policy titled Psychotropic Drug Treatment, revised 12/2016, documented facility staff would monitor for side effects, reduce dosage to the minimum required and, when possible, discontinue the use of such medications. Resident 7 (R7) R7 was admitted [DATE], readmitted [DATE], with diagnosis including acute respiratory failure with hypoxia, other symptoms and signs involving cognitive functions following cerebral infarction, and chronic pain syndrome. On 03/10/2026 in the morning, R7 was lying in bed with eyes open. R7 was observed restless, exhibiting uncoordinated movements of the arms, noted facial grimacing, and appeared uncomfortable. R7 did not verbally express needs but was able to respond to limited simple yes/no questions by nodding the head. A physician order dated 01/01/2026, documented tramadol HCI (hydrochloride), give 1 tablet via percutaneous endoscopic gastrostomy (PEG)-tube every 6 hours as needed for pain scale 7-10 (intensity of pain on a scale of 0-10). A Care Plan dated 02/26/2026, documented R7 was taking tramadol, an opioid medication, for pain medication therapy. Interventions included to monitor adverse reactions to analgesic therapy including altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, and urinary retention. The medical record lacked documented evidence tramadol HCI was monitored for side effects. On 03/13/2026 at 2:05 PM, the Director of Nursing (DON), confirmed R7's medical record lacked documented evidence of side effects monitoring for trazadone. The DON acknowledged trazadone use should have been monitored for side effects to ensure resident was not receiving more dedication than needed. A facility policy titled Medication Utilization and Prescribing – Clinical Protocol revised April 2018, documented the staff and physician will monitor for adverse effects of pain medications such as gastrointestinal bleeding from nonsteroidal anti-inflammatory drugs (NSAIDs), and anorexia, confusion, lethargy, and severe constipation related to opioids.

Based on observation, interview, record review and document review, the facility failed to ensure 1) multiple medications were not crushed altogether instead of individually and 2) a medication with specific instructions to not crush was crushed and administered as such for one unsampled resident (Resident 217). The deficient practice resulted in a significant medication error and placed the resident at risk for potential adverse effects.Findings include: Resident 217 (R217) was admitted on [DATE] with diagnoses including end stage renal disease and hemiplegia and hemiparesis following cerebral infarction.1) Crushing multiple medications togetherOn 03/11/2026 at 8:20 AM, during a medication pass observation, a Licensed Practical Nurse (LPN) prepared R217's routine medications and dispensed the following into a medication cup:-one Buspirone 5 milligrams (mg) tablet-one Hydralazine 25 mg tablet-one Amlodipine besylate 10 mg tablet-one Vitamin C 500 mg tablet- one Aspirin 81 mg chewable tablet-one Vitamin D 1,000 units tablet-one Divalproex Sodium delayed release (DR) 125 mg tablet-one Colace 200 mg tablet-two Labetalol 200 mg tablets-one Multivitamins with minerals tablet-one Zinc Sulfate 220 mg capsulesOn 03/11/2026 at 8:28 AM, a LPN put one teaspoon of apple sauce inside a medication cup, proceeded to crush R217's medications together using a pill crusher and poured the crushed medications into the medication cup containing apple sauce. The LPN explained R217 did not receive tube feedings and did not have difficulty swallowing. R217 preferred to take medications crushed mixed into apple sauce because there were too many.On 03/11/2026 at 8:35 AM, R217 was eating breakfast waffles when the LPN interrupted the meal for morning medications. R217 ingested the medications without issues.On 03/11/2026 at 8:51 AM, the LPN acknowledged crushing R217's pills together was not in accordance with facility policy. The LPN explained pills were to be crushed separately using individual pouches for more accurate documentation of actual medications administered and to ensure medications which should not be crushed were not crushed.On 03/11/2026 at 9:09 AM, the Unit Manager explained the facility protocol was to crush medications individually in separate pouches so when a medication was refused it would be easy to document accurately in the medical record. According to the Unit Manager, this practice also ensured medications which were on the DO NOT CRUSH list was not crushed. The Unit Manager acknowledged the LPN did not follow facility policy when the LPN crushed twelve pills together before administering them to R217.2) Do not crush medicationA physician order dated 03/10/2025, documented to give Depakote (Divalproex Sodium) DR 125 mg, one tablet by mouth two times a day for agitation and restlessness associated with dementia. An alert drug interaction documented, pharmacologic effects of Depakote DR may be increased by Aspirin.On 03/11/2026 at 12:56 PM, the Director of Nursing (DON) indicated medications which were enteric-coated or delayed-released must not be crushed. The DON read aloud the manufacturer's guide for Divalproex sodium DR which specifically instructed the medication be swallowed whole and must not be crushed. The DON explained medications which came as delayed release were designed to follow a mechanism for timed and steady release. The DON verbalized crushing multiple medications were to be done individually in separate pouches to ensure accurate documentation of administration and/or non-administration and in addition may impact drug-to-drug interactions.The Divalproex DR manufacturer's medication guide revised December 2025, instructed to swallow the medication whole, do not crush or chew. If patient cannot swallow whole, call healthcare provider for new medication. Divalproex DR may affect the way other medicines worked, and other medicines may affect how Divalproex DR worked. Using Divalproex with other medicines can cause serious side effects. Active ingredient: Divalproex sodium as Valproic acid.On 03/12/2026 at 10:31 AM, the Consultant Pharmacist stated Divalproex DR must not be crushed because doing so affected the release mechanism of the drug and crushing the medication would deliver the full dose immediately. The Pharmacist confirmed R217 was receiving Aspirin 81 mg and Divalproex 125 mg and the alert warning meant taking the medications together would potentially increase bleeding risk and at the same time, Aspirin could also increase Valproic acid which increased the risk for seizures. The facility's Crushing medications policy revised March 2026, documented long-acting or enteric-coated dosage forms should not be crushed, an alternative should be sought.The facility's Nursing Professional Standards on Medication Administration - Do not crush medications (undated), revealed best practice included separating crushed medications to ensure accurate dosing. Proper medication preparation and handling were essential. These standards support avoiding unsafe medication alterations, including crushing medications which may alter absorption or efficacy.

Based on observation, interview and document review, the facility failed to ensure:Open juice containers stored in the nourishment room refrigerator were labeled with an open date and a resident food item stored in the nourishment was labeled with the resident's name and used by date for 3 of 3 nourishment rooms refrigerators inspected.The deficient practice had the potential to increase the risk for foodborne illness.Findings include: On 03/10/2026 at 8:01 AM, 100 Hall nourishment room contained an open one-gallon apple juice container and an opened 3-liter cranberry juice container, which had no labeling.On 03/10/2026 at 8:05 AM, 200 Hall nourishment room contained an open one-gallon apple juice container, a 3-liter cranberry juice container and a resident food item, which had no labeling.On 03/10/2026 at 8:09 AM, 300 Hall nourishment room contained an open one-gallon apple juice container and an opened 3-liter cranberry juice container, which had no labeling.On 03/10/2026 at 8:04 AM, the kitchen team leader stated kitchen staff were responsible for labeling resident beverages stored in the resident refrigerators and should have labeled both containers before placement. The kitchen team leader clarified that resident personal food items were to be labeled by the nursing staff before food items were placed in the refrigerator.On 03/10/2026 at 8:07 AM, a Unit Manager (UM), explained all resident food items were to be labeled before being placed into the resident refrigerator for proper identification.On 03/11/2026 at 2:57 PM, a Unit Manager, (UM1), clarified that nursing staff were responsible for labelling resident food items. UM1 verbalized there were labels in each nourishment room for proper labeling. On 03/11/2026 at 2:52 PM, a Certified Nursing Assistant, (CNA), expressed not knowing that there were labels for residents stored food items.03/11/2026 at 2:59 PM, a Certified Nursing Assistant, (CNA), confirmed the resident food items were not properly labeled and verbalized resident food should be labeled with the resident's name, room number, date stored with an expiration date.The facility policy titled Food Brought by Family/Visitors (undated) documented, food brought by family/visitors left with the resident to consume later will be labeled and stored in a manner clearly distinguishable from facility prepared food.The facility policy, titled Food Receiving and Storage revised October 2017 documented, beverages must be dated when opened and discarded after twenty-four (24) hours. All food items belonging to residents must be labeled with the resident's name, the item and the use by date.

Based on interview, record review and document review, the facility failed to ensure physician's order for life-sustaining treatment (POLST) was made available to emergency personnel for a hospice resident and failed to maintain hospice paperwork in the facility in accordance with the facility policy and hospice agreement for 1 of 40 sampled residents (Resident 227). The deficient practice resulted in confusion among staff and emergency personnel and placed hospice residents at risk for advanced directives not being honored at end of life.Findings include: Resident 227 (R227) was admitted on [DATE] and readmitted on [DATE], with diagnoses including malignant neoplasm of the bronchus or lung. A POLST dated [DATE], revealed R227 did not have decisional capacity and a family member elected full code or attempt resuscitation in the event of cardiopulmonary arrest.A History and Physical dated [DATE], revealed R227 returned to the facility on [DATE] following hospitalization for acute chronic hypoxic respiratory failure. The physician previously discussed hospice which the resident and family declined. After being medically stabilized at the hospital, R227 returned to the skilled nursing facility under hospice care.A physician order dated [DATE], documented R227 under hospice care with primary diagnosis metastatic lung cancer. A general note dated [DATE], revealed R227 was found unresponsive by a nurse during morning rounds at approximately 6:00 AM. R227's still had vital signs, and hospice was notified of R227 being unresponsive and the facility nurse asked hospice to confirm R227's do not resuscitate (DNR) status. Hospice referred facility nurse to page three of the care plan which stated R227 was a DNR. R227's family was present and started doing compressions on R227 and called emergency services. Emergency services arrived at 10:05 AM and transported R227 to hospital at 10:20 AM.The medical record lacked documented evidence, a DNR POLST, and other hospice paperwork were maintained by the facility and made available to emergency services.On [DATE] at 12:37 AM, a certified nursing assistant (CNA) recalled being assigned to R227 as a sitter on [DATE] but the CNA was pulled away to provide another resident with a shower and could not speak to the event. Upon returning to the room, the CNA indicated R227 had already been sent to the hospital.On [DATE] at 9:03 AM, the Registered Nurse (RN) assigned to R227 on the day of the incident recounted doing morning rounds at start of shift and found R227 unresponsive. The RN indicated R227 appeared peaceful with no distress with presence of vital signs. The RN sought assistance from a Licensed Practical Nurse (LPN) to contact the hospice provider and R227's family. The RN recalled R227 did not have a DNR POLST in the hospice binder and the hospice provider was only able to provide a DNR election form which took a while to be received by the facility. The RN recounted the family had panicked over the resident's unresponsive state and began doing compressions while another family member called 911. The RN confirmed emergency personnel were requesting to see hospice documents and R227's DNR POLST but the facility was unable to provide this which led to the resident being transported to the hospital.On [DATE] at 9:21 AM, the Unit Manager indicated being off duty on [DATE] but was constantly receiving updates on R227's situation. R227 confirmed there was no DNR POLST in the hospice binder and hospice personnel faxed a DNR hospice election form which was signed by R227's family member and did not have a physician's signature. The Unit Manager indicated the facility was informed R227 expired shortly after arriving at the hospital. On [DATE] at 10:53 AM, an attempt to contact the hospice provider was unsuccessful.The hospice program policy dated revised [DATE], documented it was the responsibility of the facility to obtain and maintain the following information from hospice:- most recent care plan including advanced directives- hospice election form- physician certification of terminal illness/recertification- names and contact information of hospice personnel- instructions on how to access hospice's 24-hour on call system- hospice medications- hospice physician other ordersOn [DATE] at 10:53 AM, the Director of Nursing (DON) reviewed R227's medical record and indicated R227 was initially admitted on [DATE] as a full code and not a hospice resident. According to the DON, R227 was transferred to the hospital on [DATE] and returned to the facility on [DATE] under hospice care. The DON reviewed R227's hospice book and confirmed the following required information was missing namely, the hospice election form, physician certification for terminal illness, advanced directives to include a POLST reflecting DNR status. A hospice DNR election form dated [DATE], revealed R227's family member agreed to allow natural death do not perform medical procedure to try to restart heart.On [DATE] at 11:02 AM, the DON indicated the hospice provider who had oversight of R227 was responsible for completing a DNR POLST from R227's family member and clarified a DNR hospice election form was not an acceptable substitute in this state because the election form lacked a physician's order.The hospice agreement dated [DATE], documented when a resident admits into hospice, the hospice program, hospice and facility jointly developed and agreed on a hospice plan of care. Hospice and facility shall maintain a copy of each resident's hospice plan of care in the respective clinical records by each party. Coordinated care plans for residents receiving hospice services would include care and services to include advanced directives. Complaint 272374

Based on observation, interview, and document review, the facility failed to ensure a sufficient number of nursing staff were scheduled to meet the needs of the residents during the weekends of December 2024 and January through February of 2025. The deficient practice placed the residents at risk for receiving inappropriate and delayed care. Findings include: The Centers for Medicare and Medicaid Services, Payroll-Based Journal (PBJ) Staffing Data Report, dated 07/01/24 through 09/30/2024, documented the facility had excessively low weekend staffing. This was the latest report available. The Daily Staffing Plan which was provided to the surveyors documented the facility staffing needs per unit. The Licensed Nursing and CNA schedule was maintained over two separate shifts; the 6:00 AM-6:30 PM (first shift) revealed five CNAs per unit and four licensed nurses for 100 unit and three licensed nurse each for the 200 and 300 units were needed. The 6:00 PM-6:30 AM (second shift) also revealed five CNAs per unit and four licensed nurses for 100 unit and three licensed nurse each for the 200 and 300 units were needed. The Nursing Hours Per Patient Day (NHPPD) staffing document, dated 2/13/2025, documented the facility would require four licensed nurses for the 100 unit and three for each of the 200 and 300 units for the day shift and five CNAs for each 100 and 300 units and six CNAs for the 200 unit for coverage during the day. It also documented the facility would require three licensed nurses for each unit for the night shift and five CNAs for each unit for coverage during the night. NHPPD is a metric used to calculate staffing needs and to assess the quality of care and resident safety provided by nursing staff. On 02/14/2025 at 12:12 PM, the Director of Nursing (DON) and the Scheduler explained this daily staffing plan was what was used to allocate the appropriate number of staff to each unit. The only difference between the Daily Staffing Plan and the posted NHPPD was the facility was no longer using six CNAs on the day shift 200 unit, the facility was using five CNAs. The DON and Scheduler also explained the facility was using 4 licensed nurses for both day and night shift for the 100 unit, instead of the three listed on the NHPPD document. The Scheduler explained the NHPPD form and daily staffing plan had not been updated. Facility nursing schedules and timesheets documented the facility lacked adequate staffing coverage on the following weekend dates during stated shifts: - December 1, 2024, the facility was missing one licensed nurse and three CNAs on dayshift as well as one licensed nurse and two CNAs on the nightshift. - December 7, 2024, the facility was missing one licensed nurse and one CNA on dayshift as well as one licensed nurse and three CNAs on the nightshift. - December 8, 2024, the facility was missing one licensed nurse and two CNAs on dayshift as well as one licensed nurse and three CNAs on the nightshift. - December 14, 2024, the facility was missing one licensed nurse and one CNA on dayshift as well as one licensed nurse and two CNAs on the nightshift. - December 15, 2024, the facility was missing one licensed nurse and two CNAs on dayshift as well as one licensed nurse and two CNAs on the nightshift. - December 21, 2024, the facility was missing one licensed nurse and three CNAs on dayshift as well as one licensed nurse and three CNAs on the nightshift. - December 22, 2024, the facility was missing one licensed nurse on dayshift as well as one licensed nurse and three CNAs on the nightshift. - December 28, 2024, the facility was missing one licensed nurse and two CNAs on dayshift as well as one licensed nurse and three CNAs on the nightshift. - December 29, 2024, the facility was missing one licensed nurse on dayshift as well as one licensed nurse on the nightshift. - January 4, 2025, the facility was missing one licensed nurse and one CNA on dayshift as well as two CNAs on the nightshift. - January 5, 2025, the facility was missing one licensed nurse on dayshift as well as three CNAs on the nightshift. - January 11, 2025, the facility was missing one licensed nurse on dayshift as well as one licensed nurse and two CNAs on the nightshift. - January 12, 2025, the facility was missing one licensed nurse on dayshift as well as two CNAs on the nightshift. - January 18, 2025, the facility was missing one licensed nurse on dayshift as well as one licensed nurse and two CNAs on the nightshift. - January 19, 2025, the facility was missing one licensed nurse on dayshift as well as two CNAs on the nightshift. - January 25, 2025, the facility was missing three CNAs on the nightshift. - January 26, 2025, the facility was missing one licensed nurse on dayshift as well as three CNAs on the nightshift. - February 1, 2025, the facility was missing two CNAs on dayshift as well as one licensed nurse and four CNAs on the nightshift. - February 2, 2025, the facility was missing one licensed nurse and one CNA on dayshift as well as three CNAs on the nightshift. - February 8, 2025, the facility was missing three CNAs on the nightshift. - February 9, 2025, the facility was missing three CNAs on the nightshift. On 02/12/2025 at 08:23 AM a CNA was interviewed whom stated was assigned 15 residents, which was standard, and when someone calls off or they are working short, the CNA was assigned 20 residents. The CNA indicated 15 or more residents was too many. The resident care could be done, but not with the quality the CNA wants, or the residents need. on 02/12/2025 at 2:01 PM, during the resident council meeting Resident #174 stated had to wait for more than 6 hours for someone to answer the call light on the 6:00 AM to 6:00 PM shift because they are constantly short on the weekends. Unsampled Resident #207 stated weekend staffing is consistently low, especially on night shift. There were only two nurses at night in the 100 hall, but 5 were scheduled. The CNAs are overworked and end up quitting. On 02/14/2025 at 12:12 PM, the Director of Nursing (DON) and the Scheduler verified the schedules were correct and the facility did not have the above positions filled for the dates referenced above. The DON stated they have seen increased staff complaints due to the low weekend staffing as well staff burnout where staff transfer from these positions to weekday day positions as soon as one becomes available. The DON also expressed management saw resident complaints increased as well as call light answer times increased due to the low weekend staffing. The Centers for Medicare and Medicaid Services, Payroll-Based Journal (PBJ) Staffing Hours per Resident Day (HRD), dated 04/01/24 through 06/30/2024, documented the facility was utilizing 2.1 total nursing hours (RN, LPN, and CNA) of nursing care per patient per day on weekends. The national average was 3.355 of total nursing hours (RN, LPN, and CNA) of nursing care per patient per day on weekends. The facility was utilizing 1.255 hours less than the average facility. This was the latest CMS staffing hours available. HRD is the overall time expended by nurses and nursing assistants providing care to the residents on their unit per resident day excluding vacation time, sick time, orientation time, educational leave, or meeting times. The PBJ data affects the facility's star rating, which currently is a one-star rating effective January 2025, prior to that the facility was a two-star rating. According to CMS Nursing Services, the facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each resident's basic needs and individual needs as required by the resident's diagnoses, medical condition, or plan of care. 40131 On 02/12/2025 at 8:22 AM, two Certified Nursing Assistants (CNAs) reported challenges in meeting resident needs such as showering, turning and repositioning, transfers, and feeding due to the higher acuity in 100 halls, where most residents were totally dependent on staff. Three meal trays were to be passed daily, residents were to be cleaned, and more than 12 residents were assigned to each CNA for care. Both CNAs indicated difficulty in taking breaks, with only a 30-minute lunch break allowed for the entire day. Some Licensed Nurses did not assist CNAs, either due to being busy with their own tasks or too tired. On 02/12/2025, a Registered Nurse (RN) reported the facility was previously on 12-hour shifts before transitioning to 8-hour shifts, which disrupted continuity of care, and then returned to 12-hour shifts. The 100 halls should have had four nurses assigned during the day shift due to the workload's acuity, but staffing shortages left only three nurses. The census was divided among three nurses in 100 halls, where most residents were on ventilators or dependent on tube feeding, and required two staff members for bed mobility and transfers.

Based on observation, interview, record review, and document review, the facility failed to remove discontinued and expired medications and supplies from the active supply in 2 of 3 medication rooms. This deficient practice had the potential to result in medication errors, including the unintentional administration of discontinued medications, posing a risk to resident safety and well-being. Findings include: On 02/13/25 at 9:11 AM, the medication room in 200 Hall was inspected, accompanied by a Licensed Practical Nurse (LPN1). The LPN indicated the Licensed Nurse on duty was responsible for monitoring expiration dates and discontinued medications, with the Unit Manager overseeing the process. The LPN explained expired and discontinued medications should have been separated or removed from the active supply for destruction or return to the facility. The LPN confirmed the following medications had been discontinued for discharged residents, and some had expired. The LPN explained these medications had already been removed from the active supply but was unaware of the reason for being kept and mixed back in. On 02/13/25 at 9:20 AM, the Unit Manager (UM) in 200 Hall verified and confirmed the medications had been discontinued and some had expired. The UM explained medications should have been removed from the active supply for destruction. The medications were as follows: Discontinued Medications: -2 vials Cefepime 2 grams - Discontinued on 08/27/2024 -4 vials Teflaro 600 mg - Discontinued on 11/29/2024 -9 vials Meropenem 1 gram - Discontinued on 08/29/2024 -1 bag Sodium Chloride 0.9% solution 100 mL - Discontinued on 02/02/2025 -1 bag Sodium Chloride 0.9% 1000 mL - Discontinued on 02/02/2025 Expired Medications and Supplies: -15 containers of BD SurePath collection - Expired on 12/01/2024 -8 boxes of BinaxNOW - Expired on 01/23/2024 On 02/13/25 at 10:02 AM, the medication room in 300 Hall was inspected, accompanied by another Licensed Practical Nurse (LPN). The LPN indicated discontinued medications should have been removed from the active supply and placed in the designated bin under the counter in the medication room for destruction. The LPN explained this process was intended to prevent medication administration errors. The LPN confirmed the following medication, discontinued on 02/09/2025, had not been removed from the active supply: -4 Lovenox 40 mg injection syringes - Discontinued on 02/08/2025 On 02/13/2025 at 10:15 AM, the UM confirmed the Lovenox injections for the resident had been discontinued upon discharge and should have been removed from the active supply. The UM acknowledged responsibility for checking the medication room but missed separating the medication. A facility policy titled Storage of Medications revised in September 2019, outlined all drugs and biologicals were to be stored in a safe, secure, and orderly manner. The policy indicated discontinued or expired drugs and biologicals were not to be used and had to be either returned to the dispensing pharmacy or destroyed.

Based on interview, record review and document review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) level two referrals were completed for residents with newly identified psychiatric diagnoses for 5 of 35 sampled residents (Residents 24, 119, 110, 88 and 81). The deficient practice had the potential to deprive the residents of concern of necessary behavioral health services. Findings Include: Resident #24 (R24) R24 was readmitted on [DATE], with diagnoses including congestive heart failure, type 2 diabetes mellitus, chronic pain syndrome, and bipolar disorder. A PASARR level one document dated 10/19/2018, revealed R24 did not have dementia, mental illness (MI), intellectual disability (ID), mental retardation (MR), or any related condition (RC) and was deemed appropriate for nursing facility (NF) placement. A review of the resident's medical notes revealed R24's bipolar disorder was diagnosed on [DATE], during an admit at an acute care hospital. A review of the recent nursing behavioral documentation documented resistance of care on 04/21/2024, 04/24/2024, 04/30/2024, 05/05/2024, and 02/04/2025. The nursing behavioral documentation documented screaming/yelling at staff/other residents on 04/25/2024, 11/24/2024, 12/31/2024, 01/15/2025, and 01/17/2025. The nursing behavioral documentation documented disrupting the unit and other persons on 01/20/2025. Resident #119 (R119) R119 was readmitted on [DATE], with diagnoses including heart failure, type 2 diabetes mellitus, generalized anxiety disorder, depression, bipolar disorder, and post-traumatic stress disorder. A PASARR level one document dated 03/27/2006, revealed R119 did not have dementia, mental illness (MI), intellectual disability (ID), mental retardation (MR), or any related condition (RC), and was deemed appropriate for nursing facility (NF) placement. A review of the resident's medical notes revealed R119's depression and post-traumatic stress disorder were diagnosed on [DATE], during an admit at an acute care hospital due to a change in the resident's mental condition at the facility on 03/14/2024. A review of the recent nursing behavioral documentation documented resistance of care on 04/01/2024, 04/04/2024, 04/15/2024, 04/28/2024, 04/29/2024, 05/30/2024, and 09/02/2024. The nursing behavioral documentation documented screaming/yelling at staff/other residents on 04/01/2024, 04/02/2024, 11/24/2024, and 12/14/2024. The nursing behavioral documentation documented disrobing on 04/02/2024 and other observed behaviors on 03/31/2024, 04/07/2024, 04/09/2024, and 06/22/2024. The medical record lacked documented evidence R24 and R119 were referred for a PASARR level two after newly identified psychiatric diagnoses. 40142 Resident 110 (R110) R110 was admitted on [DATE] and readmitted [DATE], with diagnoses including hemiplegia with hemiparesis following cerebral infarction. A pre-admission screening and resident review (PASARR) level one dated 09/26/2019, documented R110 did not have MI, MR, IC, RC and was appropriate for NF placement. The Annual minimum data set (MDS) dated [DATE], documented R110 had no psychiatric diagnoses and was not receiving any psychotropic medications. A psychiatric follow up note dated 06/14/2021, revealed R110 was diagnosed with bipolar disorder and was started on an anti-depressant. The Annual MDS dated [DATE], documented R110 had a new diagnosis of depression and was on an anti-depressant. The Annual MDS dated [DATE] documented R110 had a new diagnosis of bipolar disorder and was on an anti-depressant. The Annual MDS dated [DATE] documented R110 had bipolar disorder and depression and was on an anti-depressant. The medical record lacked documented evidence the resident was referred for a PASSAR level two after newly identified psychiatric diagnoses. Resident 88 (R88) Resident # 88 was admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral infarction due to embolism and schizoaffective disorder. The Annual MDS dated [DATE], documented R88 was admitted with a negative PASARR level one (no MI, MR, IC or RC), did not have an active psychiatric diagnosis and was not receiving any psychotropic medications. A psychiatric consult note dated 06/20/2021, revealed R88 was diagnosed with anxiety disorder and paranoid schizophrenia. The Annual MDS dated [DATE], documented R88 had anxiety and schizophrenia and was receiving psychotropic medications. The medical record lacked documented evidence the resident was referred for a PASSAR level two after newly identified psychiatric diagnoses Resident 81 (R81) R81 was admitted on [DATE] and readmitted on [DATE], with diagnoses including spondylosis without myelopathy, schizoaffective disorder and depression. A PASARR level one dated 05/18/2022, documented R81 did not have MI, MR, IC and dementia. Appropriate for NF placement but may need a level of care (LOC) assessment. The Admission MDS dated [DATE], documented R81 did not have psychiatric diagnoses and was not receiving psychotropic medications. A hospital discharge summary revealed R81 was diagnosed with schizophrenia diagnoses and was started on Risperidone (anti-psychotic). The Annual MDS dated [DATE], documented R81 had a diagnosis of schizophrenia and depression and was receiving an anti-psychotic medication and an anti-depressant. The medical record lacked documented evidence R81 was referred for a PASARR level two after newly identified psychiatric diagnosis. On 12/14/2025 at 12:54 PM, the Behavioral Coordinator (BC) indicated being responsible for PASARR for the last two years and had access to the PASARR Medicaid online portal. The BC explained the purpose of PASARR was to ensure residents were appropriately placed and the facility was capable of providing necessary behavioral services as indicated in the resident's level of care (LOC) assessment. The BC indicated not being well-versed with how residents met criteria for a referral for a new LOC or a PASARR level two. The BC indicated having referred only one resident for a PASARR level two and it was a resident who had intellectual disability (ID). The BC acknowledged residents who were admitted with a negative PASARR level one but were later diagnosed with a psychiatric condition during their stay at the facility were not referred for a new LOC or a PASARR level two due to a knowledge deficit on the part of the facility. On 02/14/25 at 1:34 PM, the Director of Nursing (DON) acknowledged the facility had a knowledge deficit with the PASARR referral process. The DON indicated the facility made sure services were being provided for existing PASARR level two residents, but the inter-disciplinary team (IDT) was not well-versed on identifying residents who may have met criteria for a new LOC or PASARR two referral. The DON reviewed the PASARR policy which identified the social worker as being responsible for PASARR referral process but according to the DON, the social worker was not trained nor played a part in the PASARR process. The DON indicated not being surprised the BC had not referred any residents with newly identified psychiatric diagnoses. The Pre-Admission Screening and Resident Review (PASARR) policy revised December 2006, documented residents with level one screening who meet criteria for a mental illness, intellectual disability, or related disorders were referred to the state PASARR representative for Level two (evaluation and determination) screening process. The social worker was responsible for making referral to the appropriate state-designated authority.

Based on observation, interview, record review, and document review, the facility failed to ensure comprehensive care plans were revised to reflect new interventions, specifically, a nutrition care plan for 2 of 35 sampled residents (Residents 110 and 84) and a care plan for functional abilities and mobility for 2 of 35 sampled residents (Residents 156 and 67). The deficient practice had the potential to deprive residents of necessary interventions to maintain overall well-being. Findings include: Nutrition Care Plan Resident 110 (R110) R110 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction. Review of R110's medical record revealed R110 had a recorded weight of 172 pounds (lbs.) on 09/29/2024 and 157 lbs. on 12/29/2024 or a significant weight loss of 8.72 percent (%) over a three-month period. A physician's order dated 01/13/2025, documented R110 would be provided 1:1 assistance with meals at slow pace. On 02/12/2025 at 7:37 AM, R110 laid awake in bed with television on. A breakfast tray was observed on the bedside table which included scrambled eggs with melted cheese, pureed bread, a carton of chocolate health shake, a carton of chocolate milk and strawberry yogurt. R110's meal ticket documented the resident required feeding assistance. There were no staff members inside the resident's room. The medical record lacked documented evidence R110's nutrition care plan initiated on 07/22/2024, was revised to include physician's order to provide R110 with 1:1 feeding assistance on 01/13/2025. Resident 84 (R84) Resident # 84 was admitted on [DATE], with diagnoses including mild neurocognitive disorder and protein calorie malnutrition. Review of R84's medical record revealed the resident had a recorded weight of 137 lbs. on 10/26/2024 and 117 lbs. on 01/31/2025 or a significant weight loss of 14.6 % over a three-month period. A weight change note dated 02/12/2025, documented R84 had significant weight loss and required assistance with meals. A physician's order dated 01/14/2025, documented 1: 1 feeding assistance. On 02/12/25 at 7:45 AM, R84 was seated upright in bed and eating breakfast independently with no staff present. The resident's tray contained scrambled egg with melted cheese, pureed bread, Boost protein shake, a bowl of oatmeal and two cartons of orange juice. The meal ticket reflected R84 was on a soft bite-sized regular diet with thin liquids and required feeding assistance. The medical record lacked documented evidence R84's nutrition care plan initiated on 01/24/2023, was revised to include physician's order to provide R110 with 1:1 feeding assistance on 01/14/2025. Restorative Nursing Services Resident 156 (R156) R156 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. On 02/11/2025 at 10:04 AM, R156 was awake and alert in bed. R156 expressed having issues with not receiving restorative nursing services because the facility only had one restorative nurse aide (RNA). R156 indicated receiving physical therapy (PT) and occupational therapy (OT) services on admission but when insurance stopped covering the PT/OT services, the resident was placed on RNA services which used to be provided three times a week. R156 indicated two RNAs quit in October 2024 leaving the facility with one RNA. R156 pointed to a walker leaning against the wall and indicated being unable to use the walker independently and relied on the RNA to assist with ambulating. R156 indicated not being provided RNA services for over a month and the resident feared declining in strength and stamina. On 02/12/2025 at 1:10 PM, the Director or Rehabilitation (DOR) indicated being familiar with R156 who received PT/OT services from 05/16/2023 until 01/04/2024. R156 was discharged from therapy services on 01/05/2024 due to having met goals and attained maximum potential with skilled services. The DOR indicated R156 was referred to RNA services on 05/16/2024. A PT discharge summary dated 01/05/2024, documented a discharge recommendation to refer R156 to the restorative nursing program. A communication form dated 05/16/2024, documented a therapy recommendation for RNA services, specifically, ambulation using a hemi-walker 75 feet or to maximum tolerance, training with transfers form varying surfaces. Focus on ambulation program up to five days a week. The medical record lacked documented evidence R156's care plan for physical functioning initiated 05/17/2023 and care plan for risk for impaired mobility initiated on 11/29/2023, were revised to include RNA services. Resident 67 (R67) R67 was admitted on [DATE], with diagnoses including traumatic brain injury, epilepsy and gastrostomy status. On 02/11/2025 in the morning, R67 laid flat in bed, head turned towards right side, bilateral foot contractures more pronounced on the left foot were evident. Tube feeding supplies were observed inside the resident's room. On 02/12/2025 at 1:30 PM, the DOR indicated R67 was receiving PT/OT services from 04/13/2024 until 07/12/2024 and was discharged from therapy for attaining maximum potential. The DOR indicated not being aware if another therapy staff member completed a communication form which would contain specific instructions for the RNA team and whether this was communicated to the 100-Hall Unit Manager (UM). A PT discharge summary dated 07/29/2024, documented a discharge recommendation to refer R67 to the RNA program to maintain current level of performance and prevent decline. The medical record lacked documented evidence R67's care plan for mobility was revised to include therapy recommendations for RNA services. On 02/13/2025 at 11:16 AM, the Director of Rehabilitation (DOR) deferred to nursing for care plan issues. On 02/13/2025 at 11:17 AM, the Unit Manager confirmed R156's and R67's care plans were not revised to reflect therapy recommendations for RNA services, but they should have been revised to reflect provision of RNA services. On 02/13/2025 at 1:25 PM, the Director of Nursing (DON) indicated R110's and R84's nutrition care plans should have been revised when new interventions were added specifically physician's orders for 1:1 feeding assistance. The DON indicated R156's and R67's care plan for mobility and functional abilities should have been revised to include new interventions for RNA services in accordance with therapy recommendations. The Comprehensive Care Plan policy revised December 2016, documented assessment of residents was ongoing, and care plans were revised as information about the resident's condition changes. The care plan was updated when the resident's desired outcome was not met.

Based on observation, interview, record review, and document review, the facility failed to ensure restorative nursing services were provided for 2 of 35 sampled residents (Residents 156 and 67) . This failure had the potential to result in increased pain, worsening contractures, reduced mobility, and a decline in the resident's overall quality of life. Findings include: 40142 Resident 156 (R156) R156 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. On 02/11/2025 at 10:04 AM, R156 was awake and alert in bed. R156 expressed having issues with not receiving restorative nursing services because the facility only had one restorative nurse aide (RNA). R156 indicated receiving physical therapy (PT) and occupational therapy (OT) services on admission but when insurance stopped covering the PT/OT services, the resident was placed on RNA services which used to be provided three times a week. R156 indicated two RNAs quit in October 2024 leaving the facility with one RNA. R156 pointed to a walker leaning against the wall and indicated being unable to use the walker independently and relied on the RNA to assist with ambulating. R156 indicated not being provided RNA services for over a month and the resident feared declining in strength and stamina. On 02/12/2025 at 1:10 PM, the Director or Rehabilitation (DOR) indicated being familiar with R156 who received PT/OT services from 05/16/2023 until 01/04/2024. R156 was discharged from therapy services on 01/05/2024 due to having met goals and attained maximum potential with skilled services. The DOR indicated R156 was referred to RNA services on 05/16/2024. A PT discharge summary dated 01/05/2024, documented a discharge recommendation to refer R156 to the restorative nursing program. A communication form dated 05/16/2024, documented a therapy recommendation for RNA services, specifically, ambulation using a hemi-walker 75 feet or to maximum tolerance, training with transfers form varying surfaces. Focus on ambulation program up to five days a week. On 02/12/2025 at 1:16 PM, the DOR explained not all residents were candidates for RNA services but for residents who were deemed appropriate for RNA services, a communication form would be completed by a therapy staff member where recommendations would be specified such as in the case of R156. According to the DOR, the form would then be handed to the 100-Hall Unit Manager who was expected to communicate the recommendations to the RNA team. On 02/12/2025 at 1:27 PM, the DOR stated the purpose of RNA services was to maintain functional level of mobility and strength and prevent a decline in functional abilities as it pertains to activities of daily living (ADL). The DOR indicated being aware RNA services were not being provided in accordance with therapy recommendations due to the facility having only one RNA since October 2024. The DOR verbalized consequences of not receiving RNA services included a decline in functional abilities, loss of strength and stamina and development of contractures. On 02/12/2025 at 1:37 PM, the 100-Hall Unit Manager (UM) confirmed receiving R156's therapy recommendations on 05/16/2024. The UM explained the form was utilized as a reference to complete section GG (functional abilities) of the resident's minimum data set (MDS) assessment, but the recommendations were not communicated to the residents' attending physician. The UM indicated therapy recommendations should have been communicated to the physician to give the physician the opportunity on whether the therapy recommendations would be transcribed into a physician's order to ensure the services would be carried out. The UM confirmed therapy recommendations for R156 and all other residents who were deemed appropriate to receive RNA services had not been communicated to their attending physicians. On 02/12/2025 at 1:47 PM, the RNA confirmed the UM communicated R156's therapy recommendations to the RNA team on 05/16/2024 and the resident was being seen by a member of the RNA team three times a week until October 2024 when two RNAs quit. The RNA indicated being the sole RNA and was responsible for obtaining daily, weekly and monthly weights for all residents in the facility, occasionally assisted with transporting residents to appointments and currently had 20 residents on the RNA case load. The RNA verbalized it was impossible to provide RNA services by themself. On 02/13/2025 at 3:57 PM, the RNA indicated having had time to review R156's medical record and confirmed the resident was seen a total of eight times from 11/03/2024 through 02/13/2025 which was below therapy recommendations. Resident 67 (R67) R67 was admitted on [DATE], with diagnoses including traumatic brain injury, epilepsy and gastrostomy status. On 02/11/2025 in the morning, R67 laid flat in bed, head turned towards right side, bilateral foot contractures more pronounced on the left foot were evident. Tube feeding supplies were observed inside the resident's room. On 02/12/2025 at 1:30 PM, the DOR indicated R67 was receiving PT/OT services from 04/13/2024 until 07/12/2024 and was discharged from therapy for attaining maximum potential. The DOR indicated not being aware if another therapy staff member completed a communication form which would contain specific instructions for the RNA team and whether this was communicated to the 100-Hall Unit Manager (UM). A PT discharge summary dated 07/29/2024, documented a discharge recommendation to refer R67 to the RNA program to maintain current level of performance and prevent decline. The medical record lacked documented evidence a communication form was completed and R67's therapy recommendations were communicated to any member of the inter-disciplinary team (IDT) which included R67's attending physician. On 02/13/2025 at 10:27 AM, the DOR indicated having spoken with the PT assigned to R67 who acknowledged failing to complete R67's therapy recommendations for RNA services. On 02/13/2025 at 10:30 AM, the Unit Manager and RNA confirmed not receiving therapy recommendations for RNA services for R67 and confirmed R67 had never been on the RNA case load and the resident had not been provided any RNA services since being discharged from PT/OT services in July 2024. The DON, Unit Manager and RNA acknowledged there was a breakdown in communication which resulted in R67 not receiving RNA services in accordance with PT recommendations since July 2024. On 02/13/2025 at 1:07 PM the Director of Nursing (DON) indicated therapy recommendations for RNA services should be communicated to the resident's attending physician to give the physician the opportunity to decide on whether to transcribe the recommendations into a physician's order. The DON verbalized therapy recommendations which were conveyed to the 100-Hall UM should not be used merely to complete section GG of the MDS but communicated to the physician and IDT to ensure the services were carried out. The DON confirmed the facility used to have three RNAs but two RNAs quit in October 2024. The DON indicated it was unreasonable to expect one RNA to obtain weights for all residents in the facility and provide RNA services for 20 residents. The DON verbalized it was fair to confirm RNA services were not being provided to R156 and other residents on the RNA case load. The DON indicated depriving residents of RNA services could lead to decline in function. The Restorative Nursing Services policy revised July 2017, documented residents would receive nursing care needed to help promote optimal safety and independence. Residents may be started on the RNA program upon admission, during the course of stay, or upon discharge from rehabilitation services.

Based on observation, interview, record review and document review, the facility failed to ensure feeding assistance was provided timely for residents with orders for one-on-one (1:1) feeding assistance with meals for 2 of 35 sampled residents (Residents 110 and 84). The deficient practice potentially contributed to the residents' significant weight loss. Findings include: Resident 110 (R110) R110 was admitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction. Review of R110's medical record revealed R110 had a recorded weight of 172 pounds (lbs.) on 09/29/2024 and 157 lbs. on 12/29/2024 or a significant weight loss of 8.72 percent (%) over a three-month period. A physician's order dated 01/13/2025, documented R110 would be provided 1:1 assistance with meals at slow pace. On 02/12/2025 at 7:37 AM, R110 laid awake in bed with television on. A breakfast tray was observed on the bedside table which included scrambled eggs with melted cheese, pureed bread, a carton of chocolate health shake, a carton of chocolate milk and strawberry yogurt. R110's meal ticket documented the resident required feeding assistance. There were no staff members inside the resident's room. On 02/12/2025 at 7:40 AM, R110 had difficulty mouthing words but was able to express self when given time to speak. R110 indicated being unable to feed self and relied on staff for help with eating. R110 indicated staff often left the resident's meal tray on the bedside table and returned later, sometimes up to one hour before returning to assist the resident. R110 indicated by the time staff returned to provide assistance with meals, the resident's food would get cold, and the shakes, milk and yogurt became warm which affected the resident's appetite. On 02/12/2025 at 7:56 AM, a Certified Nursing Assistant (CNA1) was observed assisting R110 with breakfast. CNA1 acknowledged serving R110's tray at around 7:30 AM and returned to the resident's room around 7:45 AM to assist the resident. CNA1 explained being assigned to provide care for 15 residents, three of whom required 1:1 assistance with meals. CNA1 explained assisting a resident with meals took anywhere from 15 minutes to 30 minutes depending on the resident. According to CNA1, R110 typically took 20 to 25 minutes to eat due to slow pace related to aspiration precautions. On 02/12/2025 at 8:00 AM, R110 told CNA1 being done with breakfast. CNA1 indicated R110 did not finish breakfast, and the meal consumption would be documented as 75% and the shake supplement would be documented at 60% while the yogurt was refused due to being warm. Resident 84 (R84) Resident # 84 was admitted on [DATE], with diagnoses including mild neurocognitive disorder and protein calorie malnutrition. Review of R84's medical record revealed the resident had a recorded weight of 137 lbs. on 10/26/2024 and 117 lbs. on 01/31/2025 or a significant weight loss of 14.6 % over a three-month period. A weight change note dated 02/12/2025, documented R84 had significant weight loss and required assistance with meals. A physician's order dated 01/14/2025, documented 1: 1 feeding assistance. On 02/12/25 at 7:45 AM, R84 was seated upright in bed and eating breakfast independently with no staff present. The resident's tray contained scrambled eggs with melted cheese, pureed bread, Boost protein shake, a bowl of oatmeal and two cartons of orange juice. The meal ticket reflected R84 was on a soft bite-sized regular diet with thin liquids and required feeding assistance. On 02/12/2025 at 7:48 AM, CNA2 entered R84's room and began to assist the resident with breakfast. CNA2 explained R84 did not have dysphagia (difficulty swallowing) and was not on aspiration precautions however, R84 had significant weight loss and fluctuating meal consumptions due to cognition issues and had orders for 1:1 feeding assistance. CNA2 acknowledged the resident's tray was served ahead of staff assistance. CNA2 explained being assigned 15 residents, three of whom required assistance with meals and CNA2 had assisted another resident prior to R84. On 02/12/2025 at 8:59 AM, the Unit Manager confirmed Residents 110 and 84 had recently identified significant weight loss and had physician's orders for 1:1 feeding assistance. The Unit Manager confirmed CNA1 and CNA2 were assigned to provide care for 15 residents each and both CNAs were assigned three residents each who needed feeding assistance. The Unit Manager indicated CNAs must distribute meal trays to independent residents first and leave meal trays in meal carts until the CNAs were ready to serve and assist residents who required feeding assistance. The Unit Manager indicated R110's tray should not be placed in the room prior to staff assistance because the improper food temperatures may affect the resident's appetite and consumption. The Unit Manager indicated R84 was not on aspiration precautions but had fluctuating meal intakes which an intervention of 1:1 feeding assistance was deemed necessary by the inter-disciplinary team (IDT) for more consistent meal consumption. The Unit Manager defined 1:1 feeding assistance to mean staff would provide assistance to the resident from tray service to tray collection, beginning to end. On 02/12/2025 at 9:07 AM, the Unit Manager indicated being employed for six years and recounted the facility used to have a restorative dining program where all residents who required assistance or supervision were transported to the restorative dining room where staff were able to provide assistance to multiple residents at the same time. The Unit Manager indicated the restorative dining program was discontinued during COVID and had not been resumed or revisited by the facility since. On 02/13/2025 at 9:00 AM, the Registered Dietitian (RD) confirmed Resident 110 had significant weight loss and physician's orders for 1:1 feeding assistance. The RD explained R110 had expressed a dislike for chocolate shakes and milk and a preference for vanilla shakes and milk. The RD verbalized being disappointed R110 was served chocolate shake/milk instead of vanilla and was provided feeding assistance more than 15 minutes after tray service where food may have been served in improper temperature. On 02/13/2025 at 9:05 AM, the RD confirmed R84 had significant weight loss and had orders for 1:1 feeding assistance due to weakness and increased confusion resulting in inconsistent meal consumption. The RD expressed disappointment to learn staff was not present when R84's breakfast tray was served. The RD corroborated the Unit Managers recollection the facility used to have a restorative dining program where residents who required supervision or assistance were transported to the restorative dining room where staff were able to assist multiple residents at the same time. The RD indicated the restorative dining program had not resumed even after COVID restrictions were lifted but the RD did not know why. On 02/13/2025 at 12:52 PM, the Director of Nursing (DON) indicated expecting meal trays to remain in meal carts until staff were ready to serve the resident's tray and provide assistance because food served in improper temperatures could impact a resident's meal consumption. The DON indicated 1:1 feeding assistance meant staff were expected to be present and providing assistance to the resident from the beginning of the meal until completion. The DON indicated physician's orders for 1:1 feeding assistance must be followed. The DON indicated beginning employment in September 2021 and there was no restorative dining program in place due to COVID restrictions. The DON indicated restoring the RNA dining program had not been discussed in IDT and Quality Assurance Performance Improvement meetings. The Supporting Activities of Daily Living (ADL) policy, revised March 2018, documented appropriate care, and services would be provided to residents unable to carry out ADLs such as dining.

Based on observation, interview, record review, and document review, the facility failed to ensure the enteral feeding was completely delivered as ordered or the duration of the order was clarified for 1 of 35 sampled residents (Resident 105), and the head of the bed was elevated during enteral infusion for 1 of 35 sampled residents (Resident 136). This failure could result in inadequate nutrition and hydration and an increased risk of aspiration pneumonia or other complications for residents. Findings include: Resident 105 (R105) R105 was admitted on [DATE], with diagnoses including bed confinement and gastrostomy. A Physician Order dated 09/16/2024 documented to infuse Jevity 1.2 tube feeding formula, volume: 1400 milliliters (ml), calories: 1680, rate: 70 ml per hour. A Care Plan dated 06/06/2022, documented R105 required tube feeding (TF) related to Pelizaeus-Merzbacher disease (a rare genetic condition that causes movement and coordination problems due to faulty nerve protection). The goal was to maintain adequate nutritional and hydration status, weight stability, and no signs or symptoms of malnutrition or dehydration. On 02/11/2025 at 10:37 AM, R105 was lying in bed, and the TF Jevity 1.2 was paused. The TF bag was unlabeled except for R105's name. The head of the bed was not elevated. On 02/12/2025 at 8:00 AM, R105 was lying in bed, and the TF was not infusing. On 02/13/2025 at 8:41 AM, R105 was lying in bed, and Jevity 1.2 was infusing at 70 ml per hour, along with water flushes. On 02/14/2025 in the afternoon, a Registered Nurse (RN) indicated the tube feeding (TF) was supposed to run for 20 hours, starting at 2:00 PM until 10:00 AM. The RN indicated the pump prompted feed complete and beeped when the feeding was finished. The RN indicated frequent interruptions occurred during the day due to the provision of care, such as wound and continence care. The RN indicated the new feeding tubing clogged easily because the tubing was thin, and the formula was thick. The RN conveyed sometimes the feeding had not been completed and was unaware of how to check the feeding pump to determine if the resident had received the complete volume of the TF formula. The Medication Administration Record from 02/11/2025-02/14/2025, documented R105's TF Jevity volume dose was completely delivered at 1400 ml per day or 4200 ml for three days. On 02/14/2025 at 1:56 PM, the Unit Manager (UM) verified at the bedside and confirmed R105's Jevity TF formula dose was not completely delivered as ordered. The UM indicated the prescribed rate was 70 ml per hour, totaling 1,400 ml daily and 4,200 for three days. The UM confirmed over three days, only 2,979 ml had been delivered, leaving a deficit of 1,221 ml. The UM indicated the TF order should have been clarified regarding the number of hours it should run, or to be continued until the full dose was delivered to compensate for interruptions due to the provision of care. The UM indicated this deficit could lead to potential malnutrition or weight loss, if the TF was not properly administered. On 02/14/2025 at 3:33 PM, during a telephone interview, the Registered Dietitian (RD) confirmed R105's TF order was to infuse 70 ml per hour for 20 hours continuously, starting at 2:00 PM and ending at 10:00 AM, totaling 1,400 ml per day. The RD indicated a deficit of 1,221 ml was significant and expected the full TF volume to be delivered to meet the resident's daily caloric requirements. The RD acknowledged in case of interruptions, TF should have been infused until the volume dose was completely delivered. The RD indicated the ongoing deficit, with an estimated loss of approximately 488 calories daily, had the potential to contribute to resident's further weight loss or malnutrition. The RD confirmed significant weight loss had occurred, but R105's body mass index remained stable at 23.8. A facility policy titled Enteral Tube Feeding via Continuous Pump revised in 2018, documented the need to verify a physician's order for the procedure. The policy required reviewing the resident's care plan and addressing any special needs. It also stated the formula label should include initials, date, and time the formula was hung/administered, and the label should be initialed to confirm it was checked against the order. Facility procedures for administration times were to be followed. 41903 Resident 136 Resident 136 (R136) was admitted [DATE] and readmitted [DATE], with diagnosis including cerebral palsy unspecified, dependence on respirator (ventilator status) and functional quadriplegia. A Care Plan dated 12/17/2024, documented R136 required tube feeding related to dysphagia. R136 would be free of aspiration and of side effects or complications related to tube feeding. Interventions included to elevate the head of the bed (HOB) during and thirty minutes after the tube feeding. A Physician order revised 07/06/2024, documented enteral feed formula Jevity 1.2, volume 1300 cubic centimeters (cc), calories 1560, and rate 65 cc per hour. A Physician order revised 03/19/2024, documented to elevate HOB 30-45 degrees during and one hour after feeding. On 02/11/2025 at 9:20 AM, R136 was observed in bed lying on their back, face turned slightly to the right and covered by a blanket up to the neck. R136's arms appeared contorted under the blanket. R136 was resting with eyes closed. R136's head of the bed (HOB) was observed flat, not elevated while the tube feeding pump was on and running at 65 milliliters an hour. On 02/11/2025 at 09:22 AM, a Registered Nurse (RN) Unit Manager, confirmed R136's HOB was not elevated, and the resident was lying flat. The RN Unit Manager acknowledged the HOB should have been elevated 35-45 degrees to prevent aspiration of the feeding formula and complications. The RN Unit Manager reported staff may have recently cleaned the resident and missed to elevate the HOB when the task was completed. On 02/14/2025 at 12:50 PM, the Director of Nursing (DON) explained residents receiving tube feeding must have the HOB elevated 30-45 degrees to prevent aspiration and resulting complications. The DON reported staff were trained to raise the HOB for tube feeding and if resident care was provided where the HOB was momentarily lowered, it needed to be raised again. A facility policy titled Enteral Tube Feeding via Continuous Pump revised November 2018, documented steps in the procedure included to position the head of the bed at 30-45 degrees (semi-Fowler's position) for feeding unless medically contraindicated.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician's order for Oxygen (O2) use and care orders were obtained and implemented, and Oxygen saturation was monitored for 1 of 35 sampled residents (Resident 68). This deficient practice had the potential to result in improper Oxygen administration, delays in necessary treatment, and potential harm to the resident's health and well-being. Findings include: Resident 68 (R68) R68 was admitted on [DATE], with diagnoses including shortness of breath and pulmonary disease. On 02/11/2025 at 8:51 AM, R68 was lying in bed with eyes closed. O2 was flowing at 2 liters per minute (LPM) via nasal cannula connected to the wall O2, and the humidifier bottle was undated and empty. No signs or symptoms of respiratory distress were noted. On 02/12/2025 at 10:25 AM, R68 was lying in bed, awake, and verbally responsive. O2 was flowing at 2 LPM via nasal cannula, and the humidifier bottle remained undated and empty. R68 indicated being O2 dependent and received continuous O2 administration by staff. R68's medical records lacked documented evidence a physician's order for O2 use and care orders were obtained, transcribed, and implemented. On 02/14/2025 at 10:42 AM, a Registered Nurse (RN) indicated familiarity with R68 and confirmed continuous O2 use. The RN verified the absence of an O2 order and explained care orders were not transcribed until 02/13/2025. The RN explained if a resident was on O2, an order was required to be obtained, transcribed into the medication administration record, included in the care plan, and implemented accordingly. On 02/14/2025 at 10:48 AM, the Unit Manager (UM) indicated O2 use required assessment, a care plan, and transcription of batch orders, including tubing changes, humidifier care, and O2 saturation monitoring. The UM verified and confirmed no O2 orders were in place until 02/13/2025. The UM also expressed being unable to determine when O2 use began due to the lack of documentation. On 02/14/2025 at 1:32 PM, the Director of Medical Records confirmed the absence of documentation or assessment regarding the resident's O2 use until 02/13/2025. A facility policy titled Oxygen Therapy, revised in January 2019, documented the facility's responsibility to provide Oxygen to residents in a safe and therapeutic manner. The administration of Oxygen therapy was required to be based on physician's orders. Humidifiers and tubing were to be labeled and dated. An appropriate plan of care was to be developed to reflect the resident's current condition and include the use of Oxygen per physician's orders.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician's order for dialysis was transcribed, the dialysis access was monitored, and vital signs were obtained and documented pre- and post- dialysis for 1 of 35 sampled residents (Resident 166). This deficient practice could have the potential to increase the risk of bleeding, infection, hypotension, and inadequate dialysis, compromising the resident's health and safety. Findings include: Resident 166 (R166) R166 was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease and dependence on renal dialysis. The Quarterly Minimum Data Set, dated dated [DATE], documented the brief interview of mental status for R166 with a score of 15/15, indicating cognitive status was intact and dialysis had been provided. On 02/11/2025 at 9:17 AM, R166 was verbally alert and oriented, seated in the wheelchair, with a dialysis port in place on the right chest. R166 indicated receiving dialysis treatment three times a week with chair time from 11:00 AM to 3:00 PM. R166's medical records lacked documented evidence a physician's order for dialysis was transcribed, the dialysis access was monitored, and vital signs were obtained and documented before and after dialysis. On 02/12/2025 at 8:30 AM, R166 was seated in the wheelchair expecting dialysis treatment scheduled for that day. R166 indicated the dialysis port was assessed in the dialysis center, but not assessed in the facility. R166 verbalized the vital signs were taken at 4:00 AM but not taken in the facility upon return post-dialysis. On 02/12/2025 in the morning, a Licensed Practical Nurse (LPN) indicated the resident's vital signs should have been taken a few minutes prior to leaving for the dialysis center and not using the same vital signs taken earlier in the morning, as the vital signs could have changed after the medications were administered and to prevent hypotension. The LPN indicated the assessment should have been documented in the dialysis communication form to be filled out by the facility and the dialysis center. On 02/12/2025 at 9:59 AM, Registered Nurse (RN) indicated the dialysis access should have been monitored for patency or, in the case of an arteriovenous access, for bruit and thrill to ensure it was functioning properly. The RN indicated the neurological assessment, and vital signs should have been completed in a timely manner. The RN explained the importance of obtaining new vital signs before dialysis treatment and immediately upon the resident's return to the facility post-dialysis to monitor for potential hypotension. The RN indicated using a communication dialysis form wherein the pre and post assessment were documented in the form. On 02/12/2025 at 9:19 AM, the Unit Manager (UM) explained if a resident had been admitted with dialysis treatment, batch orders should have been transcribed into the Medication Administration Record (MAR), including the name of the dialysis center, its address, phone number, and chair time. The UM indicated the IV access should have been assessed for bleeding and signs of infection. The UM explained vital signs should have been taken before the resident left the facility for dialysis and obtained immediately upon return to the facility post-dialysis. The UM explained the facility utilized a dialysis communication form to be filled out with information at the facility, brought to the dialysis center, completed by the dialysis center during dialysis, and returned to the facility for completion of the assessment and filing in the individualized dialysis binder. The UM confirmed the dialysis orders were not completely transcribed in the MAR and the dialysis communication forms had not been completed, including the assessment of the dialysis access sites and vital signs. On 02/12/25 at 9:45 AM, the Director of Nursing (DON) indicated pre- and post-dialysis access should have been assessed for bruit and thrill and signs and symptoms of infection. The DON indicated the dialysis access assessment was important to ensure patency for blood flow during dialysis treatment. The DON indicated vital signs should have been obtained prior to leaving for the dialysis center and upon returning to the facility post-dialysis, with documentation in the dialysis communication form. A facility policy titled Dialysis Care dated October 2019, outlined standards for residents receiving dialysis. It required shunt sites to be checked every shift and evaluated after each dialysis treatment for complications. Licensed nurses were to monitor and document pre- and post-dialysis observations, including vital signs, weight, bruits, and the shunt site for color, warmth, redness, or edema. The policy also required documentation in the resident's medical record, including dialysis orders, treatment schedule, transportation details, and dialysis center contact information.

Based on interview, record review and document review, the facility failed to assess, re-assess, and adequately monitor a resident with a change in condition for 1 of 4 sampled residents (Resident 3). The deficient practice: 1) resulted in an acute physical decline that contributed to the resident's emergent transport to the hospital where the resident passed away, and 2) placed facility residents who had a change in condition at risk for poor clinical outcomes. Findings include: Resident 3 (R3) R3 admitted was admitted on [DATE] with diagnoses including chronic heart failure. R3 did not have any cognitive deficits and was able to make needs well known. On [DATE] at 3:49 PM, R3's family member shared having received a call from R3 on [DATE], complaining of chest pain with shortness of breath (SOB). The family member stated a chest x-ray was ordered and revealed R3 had pleural effusions (fluid in the lungs). Family member stated the resident called again on [DATE] (2 days after the chest pain and shortness of breath episode) stating not feeling well with fatigue and had indigestion. Family member stated on[DATE], R3 was transported to the hospital for worsening shortness of breath. Family member verbalized the resident was in the emergency department (ED) for a short while, then transported to the intensive care unit (ICU) where R3 passed away on [DATE]. Review of R3's clinical notes from [DATE] to [DATE] revealed the following: A change in condition progress note dated [DATE] at 3:37 PM, documented R3 was observed having shortness of breath, postnasal drip and mid abdominal pain. The note documented the resident had not complained of these symptoms before. The note revealed R3 was given a breathing treatment, and the medical provider was notified who ordered a chest x-ray. No other notes regarding R3's condition were documented until the next day on [DATE] at 2:21 PM (over 22 hours later). Additionally, the note lacked documentation to show a focused or complete respiratory, cardiac or abdominal assessments were completed to establish a baseline, possible causes of R3's symptoms. A progress note dated [DATE] at 2:21 PM, the chest x-ray ordered on [DATE], revealed R3 had cardiac enlargement, pulmonary (lung) congestion and fluid in both lungs. The note documented the findings were consistent with congestive heart failure. The medical provider was notified who then ordered a water pill. The note lacked documentation to show if any focused or complete assessments or re-assessments were completed. No other notes regarding R3's condition were documented until the next day on [DATE] at 5:52 PM (over 26 hours later). A progress note dated [DATE] at 5:52 PM, documented R3's oxygen saturations decreased while being repositioned in bed by care staff. The note documented R3's oxygen was removed for repositioning and oxygen levels dropped to ninety percent. When the repositioning was completed, the oxygen was replaced, and oxygen levels went up to ninety four percent. The note documented R3 was on three liters of supplemental oxygen with oxygen saturation percentages to be monitored. The note lacked documentation to show if the incident was reported or if any focused or complete assessments or re-assessments were completed. No other notes regarding R3's condition were documented until the next day on [DATE] at 11:52 AM (18 hours later). A progress note dated [DATE] at 11:52 AM, documented R3 was scheduled for discharge to an out of state nursing facility on [DATE]. No other notes regarding R3's condition were documented until the next day on [DATE] at 3:30 AM (15 hours later). A progress note dated [DATE] at 3:45 AM, documented at 3:30 AM, R3 had SOB and stated not feeling well. The note documented R3's blood pressure was ,d+[DATE] with oxygen saturations fluctuating between eighty-five to eighty nine percent with 3 liters of supplemental oxygen. The note showed R3's skin was cold, clammy and resident was hyperventilating. The note documented the medical provider was notified, R3 was given a breathing treatment who verbalized feeling a little better. The note documented R3's health would continue to be monitored and shift report was given to the incoming nurse. The note lacked documentation to show if any focused or complete assessments or re-assessments were completed. A progress note dated [DATE] at 10:22 AM, documented R3's family member was informed R3 was too unstable to be discharged as scheduled, due to low blood pressure and low oxygen saturation percentages. The note documented R3 was under observation. The note lacked documentation to show if any focused or complete assessments or re-assessments were completed. A progress note dated [DATE] at 4:49 PM, documented R3 was verbally responsive, on three liters of supplemental oxygen with an oxygen saturation of ninety-six percent. The note showed R3 was not in any respiratory distress and had a shower that morning. The note lacked documentation to show if any focused or complete assessments or re-assessments were completed. No other notes regarding R3's condition were documented until the next day on [DATE] at 9:03 AM (17 hours later). A change in condition progress note dated [DATE] at 09:03 AM, documented R3 complained of epigastric pain that radiated to the chest area. The note stated the medical provider was notified who ordered for R3 to be transported to the emergency department. 911 was called and resident was transported to the emergency department at 9:57 AM. A hospital progress note dated [DATE], showed R3 arrived at the hospital emergency department (ED) with shortness of breath. Testing completed in the ED revealed R3 had suffered a heart attack and was immediately sent to the intensive care unit. The note revealed R3 also had active congestive heart failure, continued to decline over the next three days and eventually passed away on [DATE] from cardiogenic shock (A cardiac condition when the heart cannot pump enough blood and oxygen to the brain and other vital organs. The condition is a life-threatening emergency, treatable if diagnosed right away. Late signs and symptoms of cardiogenic shock include a drop in blood pressure and slowing of peripheral pulses. Other symptoms include, sweating without activity and rapid breathing. Causes of cardiogenic shock included congestive heart failure and heart attack). Review of R3's care plan dated [DATE] identified R3 had pleural effusions (fluid in lungs). Goals included: R3 will maintain a patent airway as evidenced by clear lung sounds, oxygen saturation. Interventions included the following: 1. Assess lung sounds. Adventitious lung sounds such as wheezing, stridor, rhonchi, crackles can result from an accumulation of secretions or blocked airway. 2. Assess respirations. Note the depth, pattern and use of accessory muscles when breathing. Increasing rate, nasal flaring and accessory muscle use is an attempt to compensate for ineffective breathing. The care plan lacked documentation to show R3 had congestive heart failure (CHF) with specific goals with appropriate interventions. On[DATE] at 10:23 AM, a Licensed Practical Nurse (LPN) was asked to describe what the process was for a resident complaining of chest pain with SOB. The LPN stated assessing ABC's (Airway, breathing and circulation) was a priority. The LPN explained placing the resident on oxygen and checking oxygen levels by way of vital signs. LPN stated regarding the chest pain, checking orders and calling the medical provider for orders. LPN was not aware of any facility chest pain or congestive heart failure (CHF) protocol. LPN did not state performing any focused assessments such as assessing lung, heart sounds, performing a resident interview to obtain more information or follow up monitoring. On [DATE] at 10:39 AM, another LPN was asked the same question and explained getting vital signs, assessing if the pain was radiating, calling the medical provider and check for any medication orders for chest pain. LPN added did not assess lung sounds. LPN stated calling for emergency services if the resident was not responsive. On[DATE] at 1:15 PM, the Director of Nurses (DON) stated according to the progress notes, the resident started having SOB, postnasal drip and pain in stomach on [DATE]. DON explained R3 was given a breathing treatment, and a chest x-ray was ordered. DON stated the chest x-ray was done the next day on [DATE]. DON indicated the results of the x-ray showed R3 had CHF with pleural effusions. DON indicated on [DATE], the resident was complaining of stomach pain and sent out due to further decline. When asked if R3 should have gone to the hospital sooner, DON stated nurses could send a resident to the ED using their nursing judgment. DON agreed the nurses did not assess lung sounds, quality, duration and frequency of SOB. DON agreed most medical providers were not always in the facility and depended on the nurses to report more detailed clinical information, to make better clinical decisions. DON agreed the nurses could have sought further assessment from an RN on duty for more ongoing, clinical assessment and monitoring. DON stated there was no documentation to show evidence that the nurses provided adequate reassessment and monitoring. On [DATE] at 3:25 PM, the medical provider who recalled receiving notification R3 had SOB, explained ordering a chest x-ray and a medication on [DATE], to try and remove the fluid in R3's lungs. Provider stated it was the expectation for the nurses to report back intervention effectiveness of R3's condition, but could only recall getting a report back 4 days later when the resident had decompensated and had to be sent to the ED for evaluation. The provider indicated expecting nurses to assess each resident every shift which included obtaining vital signs and auscultation of the lungs which was basic nursing assessment. The provider indicated the nursing assessment and re-assessment was crucial as it served as the basis for physician's giving out appropriate treatment orders. The provider stated nurses had the capacity to transfer residents that were unstable to the hospital for further evaluation based on their clinical judgement and was not aware R3 later died in the hospital. Provider agreed getting more detailed clinical information from the nurses may have changed the outcome. On [DATE] at 4:56 PM, the Assistant Director of Staff Development (DSD) stated residents were assessed by licensed nurses on a daily basis. Nursing assessments included: vital signs, any change of condition. Assessments were typically done during medication pass on admission and when there was change of condition. On [DATE] at 5:01 PM, the DSD indicated nurses were expected to perform assessments every shift, unless more frequent checks were ordered by the physician. These assessments would have included vital signs (BP, pulse, pulse oximetry, respirations, temperature, pain, breathing patterns especially in SOB). The DSD indicated auscultation of the lungs should be done every shift to assess for diminished lung sounds, crackles, wheezing, etc. The DSD stated nurses were the eyes and ears of the physicians who were not always in the facility. DSD stated nursing judgments were crucial and the basis of a physician's decision-making. Nurses are trained in the SBAR process. DSD also stated the facility followed the not documented/not done rule. Meaning, to say if assessments were not documented they were not done or if a physician notification was not documented then it was not done. On [DATE] at 5:13 PM, the DSD reviewed R3's medical record and confirmed there was no documentation of daily nurses' assessment. According to the DSD the outcome may have been different if the physician notification and nursing assessments were completed in accordance with facility policies. On [DATE] at 4:53 PM, DON stated the facility did not have a policy for nursing standards of practice. DON stated nurses used the Nevada Nurse Practice Act as the standards of practice. Review of the facility policy titled Change in a Resident's Condition or Status, revised on ,d+[DATE], documented the following: 1. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant information for the provider. Review of the facility policy titled Comprehensive Assessment and the Care Delivery Process, revised on ,d+[DATE], documented the following: Assessment and information collection included (what, where and when?). The objective of the information collection (assessment) phase is to obtain, organize and subsequently analyze information about a resident. Assess the resident: 1. Gather relevant information from multiple sources including: - Observation - Physical assessment - Symptom or condition related assessment 2. Identify potential causes or contributing factors of problems and symptoms 3. Apply clinical reasoning to assessment information and determine most appropriate interventions. 4. Monitor results and adjust interventions to include, periodically reviewing progress Review of the facility policy titled Heart failure- Clinical Protocol revised ,d+[DATE], documented nurses will assess, document/report the following: - Vital signs - General physical assessment - Recent or current history of chest pain, dizziness or diaphoresis (sweating due to medical condition such as heart failure). Review of the facility policy titled Charting and Documentation revised [DATE], showed the following: - All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. - The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Complaint #: NV00072165

Based on observation, interview, record review, and document review, the facility failed to protect the resident's right to be free from neglect by providing timely incontinent care for 1 of 37 sampled residents (Resident #186). The failure to protect the resident rights from neglect places residents at risk to acquire Moisture Associated Skin Damage from being left wet in an incontinent brief for a long period of time when incontinent care was not provided timely. Findings include: Resident #186 (R186) R186 was admitted on [DATE], with diagnoses including sepsis, polyneuropathy, and obesity. The Quarterly Minimum Data Set assessment dated [DATE], documented R186 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated R186 was moderate impaired. R186 was incontinent of bowel and bladder and required extensive assist with one-person physical assist with toilet use, and extensive assist with two-person physical assist for personal hygiene. The Care Plan dated 08/10/2021 and revised on 08/10/2021, indicated the resident required supervision and set-up for personal hygiene. The care plan dated 02/12/2023, indicated a scaly rash to the left leg. On 02/14/2023 at 10:54 AM, R186 was lying in bed with a yellow stained incontinent brief and a wet chux pads underneath the lower back and thigh area. There were yellow-colored wet tissues on top of the wet chux pads on R186's right upper back and elbow area. Strong urine odor was present in the room. R186's skin redness was observed near the inner thigh and groin area. R186 indicated they were embarrassed, cold, and uncomfortable sitting in their wet incontinent brief that soaked to the bed sheet and smelled of urine, waiting all morning for a CNA to change them. R186 indicated they had eaten breakfast sitting in a wet incontinent brief, in a bed that smelled of urine. R186 verbalized not to get too close because of the unpleasant urine smell. R186 indicated their incontinent brief was wet since 5:00 AM and had been waiting for the morning Certified Nursing Assistant (CNA) to change their wet incontinent brief after shift change around 6:30 AM. R186 indicated the CNA did not come in the morning so they had rung the call bell requesting to be changed. The CNA who answered the call bell indicated they were not their CNA, and they would relay the message to their assigned CNA. R186 indicated they had told the CNA passing out the breakfast tray their incontinent brief was wet and needed to be changed but the CNA kept telling them they were not the assigned CNA and would tell their CNA again. R186 indicated they also told the Licensed Practical Nurse (LPN) when they were in room with their medication that their brief was wet and continued waiting for the CNA all morning to change their incontinent brief, but no one came. On 02/14/2023 at 12:00 PM, R186 indicated the CNA, or the nurse have not returned to change their wet incontinent brief. R186 indicated they gave up ringing the call bell because their assigned CNA was busy and kept getting the run around by the staff. On 02/14/2023 at 12:08 PM, a CNA was observed delivering R186's lunch tray into the room. On 02/14/2023 at 1:37 PM, R186 was in bed with a wet yellow stained incontinent brief with wet chux pads underneath the lower back and thigh area. There were dried yellow-colored tissues on top of the wet chux pads. R186's room smelled of urine upon entering the room. R186 indicated the CNA and nurse did not come to change their wet brief yet and they had reminded the CNA again they needed to be changed when the lunch tray was delivered. On 02/14/2023 at 1:49 PM, a CNA entered R186's room and left without changing the resident's wet incontinent brief. On 02/14/2023 at 1:53 PM, R186 indicated they told the CNA that was in the room, their wet incontinent brief needed to be changed and the CNA indicated they would be back to change them. On 02/14/2023 at 1:54 PM, two licensed nurses entered R186's room and closed the door. The Licensed Practical Nurse (LPN) and the Registered Nurse (RN) indicated they were in R186's room to change the resident because they were wet. The LPN and RN confirmed the R186's incontinent brief was wet, soaked through to the chux pads and the bed sheet. The RN and LPN indicated R186 had redness to the inner thigh and groin area from being in a wet incontinent brief for a long period of time and they applied a barrier ointment to the reddened area when changing the resident to prevent skin rashes and breakdown. The LPN indicated they were aware R186 asked for their wet incontinent brief to be changed while doing medication pass around 11:00 AM. The LPN told R186 they would tell their assigned CNA, or they would come change the resident themselves after completing medication pass if the CNA was busy. The LPN indicated the CNA was busy, so the RN came to assist with changing R186. On 02/14/2023 at 1:57 PM, CNA #3 indicated residents were checked on and changed every two hours. CNA #3 indicated they were the assigned CNA for rooms 201-214 except for room [ROOM NUMBER] which was the last room in the hall. CNA #3 indicated R186 had told the CNA two to three times earlier today that their incontinent brief was wet and needed to be changed. CNA #3 indicated they had relayed the message to R186's CNA. CNA #3 indicated they did not change R186's wet incontinent brief because they assumed the R186's assigned CNA would do it after they were told numerous times earlier in the day. On 02/14/2023 at 2:10 PM, CNA #4 indicated residents were checked on at least every two hours and incontinent care was provided if the resident was soiled. CNA #4 indicated their assigned rooms were room [ROOM NUMBER]-229 but because they were short staffed on CNAs today, room [ROOM NUMBER] was added to their assignment. CNA #4 indicated they were busy all day and did not get a chance to go to the other hall to assist the residents in room [ROOM NUMBER]. CNA #4 indicated the other CNA had notified them R186 was wet since early morning and needed to be changed but the CNA did not have time to go to the other hall to change R186 all day. CNA #4 indicated they had not changed R186 during their shift today and had to ask the LPN and RN to help change R186. On 02/16/2023 at 10:15 AM, R186 was lying in bed wearing an incontinent brief. R186 verbalized being dependent on the staff for incontinent care. R186 indicated a recent history of being left in a wet brief for an extended period, estimated to be greater than eight hours and was concerned about a possible rash as a result. On 02/16/2023 at 10:20 AM, the LPN and a CNA removed the incontinent brief to reveal an area of inflamed reddened skin covering the scrotum, the creases between the legs and scrotum, and extending down the right thigh about six inches in length and about six inches wide, with the area curving around to the posterior right thigh. R186 verbalized the area was painful. The area was consistent in appearance with moisture associated skin damage (MASD, skin damage which occurs due to prolonged contact with moisture such as urine). The LPN verbalized being unaware the resident had developed MASD. The LPN verbalized they would call the physician to obtain treatment orders. The LPN applied barrier ointment (zinc oxide). On 02/21/2023 in the morning, the Director of Nursing (DON) verbalized each incontinent resident must be checked, and wet or soiled incontinent briefs changed, every two hours at a minimum. The DON verbalized any resident who was left in a urine-soaked brief for longer than two hours was at risk for developing MASD and skin breakdown. A grievance/complaint form received on 12/21/2022, indicated R186 had complained their call light took a long time to be answered. CNAs were informed to be more vigilant in answering call light. The policy and procedure titled Recognizing Signs and Symptoms of Abuse/Neglect dated 04/2021, indicated resident abuse and neglect were strictly prohibited. Neglect was defined as failure to provide goods and services as necessary to avoid physical harm or mental anguish. Signs of neglect included poor hygiene. The policy and procedure titled Pressure Ulcer Risk/Skin Assessment, revised April 2008, indicated the facility would identify risk factors for developing pressure ulcers and provide necessary care and services that would meet the resident needs and promote skin integrity. Pressure Ulcer Risk/Skin Assessment included assess skin daily and keep skin clean and dry. The policy and procedure titled Prevention of Pressure Injuries, revised April 2020, indicated Prevention included keep skin clean and hydrated, and clean promptly after episodes of incontinence. Complaint #NV00065602, #NV00067943, #NV00067488 and #NV00067595

Based on record review, interview and document review, the facility failed to investigate an injury of unknown origin in a timely manner for 1 of 5 sampled residents (Resident #1). Findings included: Resident #1 (R1) R1 was admitted on [DATE], with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R1 was Total Dependence with Activities of Daily Living (ADL). R1 was dependent on others for all care. Care Plan dated 07/07/17, documented R1 required extensive to total assistance with bed mobility, one to two persons assistance with transfers and dressing; one person assist with eating, toileting, personal hygiene and bathing. On 11/15/19 at 9:00 AM, an interview was attempted with the resident. R1 was nonverbal and did not respond to questions. A Shower Assessment report dated 08/21/19, documented a Certified Nursing Assistant (CNA) provided a shower to R1 and documented unspecified red in abdominal area. A Nurse signed the document, the document did not indicate the time of day when the assessment was performed. A Shower Assessment report dated 08/24/19, documented R1 received a shower by a CN[NAME] The CNA documented R1 ' s skin was clear. The assessment did not specify a time the shower was given. The document was signed off by a nurse. CNA Skin Body Check reports dated 08/19/19 through 08/24/19, documented R1 did not have skin issues or concerns. A Situation, Background, Assessment, Request (SBAR) report dated 08/24/19 at 3:49 PM, documented R1 noted with a first degree burn on the abdomen above the navel. The SBAR documentation indicated the physician and family was notified. Interventions were not documented. A Treatment Wound Progress note dated 08/24/19, documented R1 had a second degree burn with small amount of serous drainage. Physician and family were notified. A treatment order to cleanse with [MEDICATION NAME] cover with dry dressing for 14 days with care plan updated. Physician order [REDACTED]. The care plan lacked documented evidence R1's second degree burn was addressed, and interventions initiated. The medical record lacked evidence the Administrator, Director of Nursing and Unit Manager were notified of the second [MEDICAL CONDITION] R1 ' s abdomen. On 11/15/19 at 11:30 AM, a CNA who provided care to R1 on 08/24/19, verbalized the wound was found during patient care and reported the findings to the Licensed Practical Nurse (LPN) in charge. The CNA indicated the report was made around 8:00 AM in the morning. On 11/15/19 at 11:38 AM, the LPN providing care to R1 on 08/24/19, indicated a CNA reported R1 had skin concerns on the abdomen. The LPN verbalized a SBAR was completed and the Physician Assistant, Wound Care Nurse and R1 ' s family were notified. The LPN acknowledged the Administrator, Director of Nursing (DON) or Supervisor on shift were not notified of the incident. On 11/15/19 at 8:55 AM, a Registered Nurse Unit Manager indicated if a wound issue was observed, the CNA should notify the nurse, treatment nurse, and unit manager. The RN Unit Manager stated the wound care team performed the assessment and notified the physician. The RN Unit Manager explained an SBAR should be completed and family notified. If abuse was suspected, notify the administrator. The RN Unit Manager indicated R ' 1s wound was brought up during a wound care meeting on 09/06/19. The RN Unit Manager stated a Self-Report was completed and the DON and the Vice President of Operations were notified the same day. The RN Unit Manager indicated several staff were interviewed for the investigation, but nobody knew how the injuries occurred. The RN Unit Manager indicated the investigations should have been performed in timely manner so information could be gathered to determine how the incident happened. The RN Unit Manager verbalized R1 required total care and was not sure how [MEDICAL CONDITION] acquired. On 11/15/19 at 8:30 AM, a CNA explained residents skin conditions were checked at the time of resident care such as toileting, shower, dressing or brief change. The CNA indicated if a new condition was found such as skin tear or open area, the charge nurse would be immediately notified. The CNA verbalized skin checks were documented in the electronic medical record. The CNA indicated any allegation of abuse/neglect must be reported immediately to the Nurse Supervisor. The CNA stated if after the report, the nurse did not act upon, the incident would be reported following the chain of command. On 11/15/19 at 8:36 AM, an LPN explained any injury of unknown origin (IUO) must be reported to the attending physician, the family and to the supervisor. The LPN indicated any new skin condition or IUO should be reported using SBAR format in the computer. The LPN verbalized residents skin conditions were checked on a daily basis and it was impossible to do not detect a new skin issue. On 11/15/19 at 1:50 PM, Wound Care Nurse verbalized the nurse called to identify marks on R ' s abdominal area. The Wound Care Nurse confirmed R1's red abdominal marks were burn wounds. Wound Care Nurse verbalized R1 ' s burn must be reported to state officials. The Wound Care Nurse indicated the abdominal marks did not look like [MEDICAL CONDITION] else it would have looked uniform in shape. The Wound Care Nurse indicated the physician was notified and treatment was initiated. On 11/15/19 at 11:45 AM, the DON agreed that R1's abdominal skin concern was an IUO and the nurse should have immediately notified the abuse coordinator who was the administrator. The DON indicated a Change of Condition Assessment should have been completed by the facility. On 11/15/19 at 1:30 PM, the Administrator agreed R1's abdominal wounds were considered IUO and an abuse and a neglect investigation should have been initiated. The Administrator verbalized staff were aware the abuse coordinator was available by phone 24 hours a day. The administrator expected the staff to report the abuse allegations to him and complete the investigation within five days of occurrence. The Administrator stated he was not aware of R1 ' s injuries. Facility policy titled Abuse Prohibition Standards of Practice dated (MONTH) (YEAR), indicated all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, should be reported immediately (not to exceed 2 hours after discovery) to the Administrator or the Director of Nursing (DON). The policy revealed if the incident was discovered after hours, the report would be given to the Charge Nurse or Supervisor in charge. The policy documented the Facility Administrator, or the designated person should report the incident to local law enforcement, the state survey agency and the Department of Family and Protective Services (if appropriate) in accordance with federal and state law. Complaint #NV 022

Based on interview, clinical record review and document review, the facility failed to 1) follow their policy and procedure regarding the assessment, care and documentation of a peripherally inserted central catheter (PICC) line and [MEDICATION NAME] lock for two residents (Resident #16 and Resident #21); 2) failed to obtain a physician's order for the insertion and removal of a [MEDICATION NAME] lock for one resident (Resident #16); and 3) Medications were not administered as ordered in a timely manner for one resident (Resident #16). Findings include: Resident #16 1. Resident #16 was admitted to the facility on [DATE], and discharged [DATE], with [DIAGNOSES REDACTED]. The nursing admission assessment dated [DATE] at 10:30 AM, documented Resident #16 was alert, oriented to person and able to follow simple commands. Ventilator and [MEDICAL CONDITION] dependent. The skin assessment dated [DATE], documented Resident #16 had a PICC line in place in the right upper arm (RUA). The admission skin check sheet dated 1/11/11, documented Resident #16 had a PICC line in the RUA. The dressing was dry and intact. Review of the nurse's notes from 1/10/11 through 1/28/11, lacked documented evidence an assessment of the PICC line had been completed. The notes lacked documentation the site and surrounding tissue had been assessed for complications, the condition of the dressing, any treatment done to the catheter or PICC site, or the line patency had been checked. The intravenous (IV) medication sheet dated 1/15/11 through 1/21/11, lacked documented evidence Resident #16's PICC line site had been assessed every shift, the PICC dressing had been changed or the injection cap changed in accordance with the facility's policy. The IV medication sheet dated 1/25/11 through 1/31/11, lacked documented evidence Resident #16's PICC line site had been assessed every shift, the PICC dressing change had been done or the injection cap changed in accordance with the facility's policy. A nurse's note dated 1/28/11 at 3:00 PM, documented Resident #16 had ongoing IV antibiotics for pneumonia. No adverse reactions noted. The nurse's notes lacked documented evidence the IV site and surrounding tissues or line patency had been assessed. A nurse's note dated 1/28/11 at 10:00 PM, documented a [MEDICATION NAME] lock was re-inserted in the right forearm with a 22 gauge, with good blood return. The medical record lacked documented evidence a physician's order had been received to discontinue Resident #16's PICC line, if the PICC line had been discontinued, or the reason why the PICC line was discontinued, the time and date it was discontinued and the condition of the site and catheter after the PICC line was removed. The medical record lacked documented evidence a physician's order had been received to insert a [MEDICATION NAME] lock. The nurse's notes dated 1/31/11 at 7:30 AM, documented a CNA (Certified Nursing Assistant) informed the nurse about a small lump on the resident's forearm. Upon assessment the lump was hard to the touch, no redness noted, skin intact. IV antibiotics infusing and almost done. Informed Supervisor who re-assessed the resident. Spouse at bedside. On 1/31/11 at 8:00 AM, the nurse's notes documented the Nurse Practitioner was paged. Lump size stayed the same, will monitor. On 1/31/11 at 12:00 PM, nurse's notes documented lump size still the same, paged MD (Medical Doctor/Physician) again. On 1/31/11 at 2:00 PM, nurse's notes documented went to resident's room to start tube feeding and noted the lump doubled in size approximately 6-7 centimeters with some skin discoloration noted. Immediately called the ADON (Assistant Director of Nursing) who came and assessed the resident with the Supervisor. Received physician's orders for STAT (as soon as possible) ultrasound of right forearm, complete blood count, basic metabolic panel and PT and INR ([MEDICATION NAME] and International Normalized Ratio). [MEDICATION NAME] lock discontinued and applied pressure on the site, no bleeding noted. Applied cold compress on lump area. The medical record lacked documented evidence a physician's order was received to insert or to discontinue the [MEDICATION NAME] lock. On 1/31/11, a physician's order was received for an ultrasound of the right forearm STAT to rule out [MEDICAL CONDITIONS]. The nurse's notes dated 1/31/11 at 9:40 AM, documented the ultra sound results on right upper extremity revealed non specific fluid collection of uncertain etiology or significance. MD on call notified with orders received to observe for further swelling. The nurse's notes dated 2/1/11, documented right forearm noted with increase in size and black/blue in discoloration. MD on call notified with order to continue to monitor. At 5:10 AM, the nurses notes dated 2/1/11, documented the writer was made aware by resident's husband the resident's right forearm was increasing in size and worsening. "It was noted upon assessment by this writer the resident's R (right) forearm increased in size from previous assessment with no improvement and discoloration." MD on call notified with order to send resident to local acute care hospital for further treatment and evaluation of right forearm. Husband made aware and at 7:50 AM, the resident was transferred via ambulance to a local acute care hospital. On 2/1/11, a physician's order was received to transfer Resident #16 to the acute care hospital for further evaluation of the swelling in right arm. The Discharge Summary documented while at the facility Resident #16 developed a [MEDICAL CONDITION] of the left arm. On the day of discharge to the acute care hospital, the patient was noted to have increased swelling in the right arm. The Resident Transfer form (Inter-agency referral) from the facility dated 2/1/11, documented the reason for transfer was to treat and evaluate secondary swelling in right arm. Additional information on the form documented increase swelling to right arm secondary to infiltrated IV. The hospital clinical nurses report dated 2/1/11 at 8:33 AM, documented Resident #16 had 4+ seeping [MEDICAL CONDITION] to the right upper extremity involving the hand and forearm The arm was darkly colored. The skin was warm and dry. The hospital clinical nurse's note documented on 2/1/11 at 11:28 AM, Resident #16's upper extremity [MEDICAL CONDITION] of the arm was now blistering and seeping clear fluids. On 2/1/11 at 3:32 PM, the nurse's note documented seeping [MEDICAL CONDITION] of the upper extremity and worsening [MEDICAL CONDITION] extending midway up the upper arm. The admitting History and Physical (H&P) from the acute care hospital dated 2/1/11, documented Resident #16 right upper extremity with significant diffused swelling and warm to touch with weeping and blistering throughout, more than double the size of her left upper extremity. Documentation from the acute care hospital indicated Resident #16's right arm had no radial or ulnar pulses, the extremity temperature was cold/moist and the extremity was pale in color. The results from a right upper extremity venous duplex ultrasound dated 2/1/11 at 10:11 AM, documented large mixed echogenicity complex fluid collection involving the ventral aspect of the arm and forearm with adjacent. Etiology was indeterminate. Correlate clinically for any possible recent trauma, instrumentation or intravenous fluid extravasation. Documentation entitled Physician Clinical report from the acute care hospital dated 2/1/11 at 8:50 AM, documented Resident #16 chief complaint was upper extremity pain and swelling. Severity was described at moderate in degree. The symptoms located in the area of the right arm, right forearm and right hand. The resident had swelling . Emergency Medical Services (EMS) stated the resident had a PICC and peripheral in her right arm. The resident developed pain, swelling and discoloration. The Physician Clinical report dated 2/1/11 at 8:33 AM, documented Resident #16's extremities: Pitting [MEDICAL CONDITION] of the right upper extremity involving the hand, forearm and arm. The right arm tenderness, moderate swelling and large ecchymosis. No puncture wound or foreign body. The right forearm tenderness, moderate swelling and large ecchymosis located in the dorsal aspect of the forearm. No puncture wound or foreign body. The right hand tenderness, moderate swelling, and large ecchymosis localized to the dorsal aspect of the hand. No puncture wound or foreign body. On 3/30/11 at 1:50 PM, a family member stated Resident #16 had a blood clot in her left arm and he saw a knot starting to form in the right arm by the PICC line. The family member stated the facility was told it was not in the vein and it was going into the "flesh".The family member was told the scan was fine. The next day the resident's right arm was black and swollen. The resident was transferred to the acute care hospital on [DATE], and passed away on 2/2/11. On 3/31/11 at 12:05 PM, Licensed Nurse (LN) #1 stated Resident #16 was admitted with a PICC line. The LN stated the PICC line site had not been monitored per the facility policy and the PICC line dressing changes and injection cap were not done per policy. The LN stated the injection cap was to be changed weekly per the policy. LN #1 stated an IV site was to be assessed every shift and documented on the Medication Administration Record or Treatment Record. LN #1 was not able to locate documentation in the medical record to indicated whether or not the PICC line had been discontinued. The LN stated there was no physician's order to discontinue the PICC line. LN #1 stated only a Registered Nurse (RN) can remove a PICC line. The LN stated when the PICC line was removed there needed to be a physician's order, documentation of any bleeding at the site after removal of the catheter and was the catheter removed intact. During the interview on 3/31/11 at 12:05 PM, LN #1 was not able to locate documentation in the medical record why the [MEDICATION NAME] lock was inserted or a physician's order for the [MEDICATION NAME] lock. The LN was not able to locate documentation a physician's order was received to discontinue the [MEDICATION NAME] lock. The employee stated there should be an order to insert or discontinue a [MEDICATION NAME] lock. On 3/31/11 at 1:20 PM, LN #1 stated if a dressing stayed in place for too long the access site could become infected and could go systemic. LN #1 stated if the IV line was not working the medication would not be given into the vein and the area will be swollen. LN#1 stated depending upon the medication if it goes into the tissue and not the vein it can cause tissue damage. The facility's policy entitled Documentation dated 7/26/04, documented "To assure safe continuum of care for the patient receiving infusion therapy and to provide legal document verifying proper care of the patient receiving infusion therapy." Documentation should include: Assessment of the site and surrounding tissue for complications Condition of the dressing Any treatment done to the catheter or site. Line patency If catheter is removed, explain the reason for the removal, condition of site, and condition of catheter. Narrative notes, check off flow sheets, or a combination of both may be used for proper documentation. The facility's policy entitled Peripherally Inserted Device dated 7/26/04, documented change dressing weekly and as needed (prn). Caps were changed weekly. 2. Resident #16's medical record contained a physician's order dated 1/25/11, for Cancidas 70 milligrams IV times one for initial dose then, Cancidas 50 milligrams IV every 24 hours for 14 days. The Medication Administration Record (MAR) dated 1/11, documented Resident #16 did not received Cancidas 70 mgs IV time one dose on 1/25/11. The medication was not given until 6:00 AM on 1/26/11. On 3/31/11 at 12:05 PM, Licensed Nurse (LN) #1 stated she did not know why the Cancidas 70 mgs IV was given on 1/26/11 and not on 1/25/11. The LN stated it would depend upon what time the medication arrived from the pharmacy. LN #1 stated when an antibiotic was ordered it took 4-6 hours to arrive at the facility from the pharmacy. However, if the medication was in stock at the facility in the Pyxis system the antibiotics can start right away. Documentation received by the facility entitled Delivery Manifest: The (facility name) - Wing 1 the medication Cancidas 70 mgs IV for the one time dose was received at the facility on 1/25/11 at 7:40 PM along with Cancidas 50 mgs IV. On 4/7/11 at 11:56 AM, a representative from the pharmacy stated the physician's order for Resident #16's Cancidas 70 milligrams IV time one for initial dose then, Cancidas 50 milligrams IV every 24 hours for 14 days was received on 1/25/11 at 4:38 PM. The medications for Resident #16 were delivered to the facility on [DATE] at 7:36 PM. On 4/8/11 at 11:30 AM, LN #2 stated if an IV antibiotic was ordered and the medication was received the expectation was the medication would be administered with in 1-2 hours. On 4/8/11 at 11:35 AM, LN #1 stated the antibiotic Cancidas was not available in the facility's Pyxis system, the Pharmacy needed to mix the medication. LN #1 stated the expectation was once an IV antibiotic was received the medication was administered with in 4 hours. Resident #21 Resident #21 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The medical record contained admission orders [REDACTED]. The Admission Skin Check list form dated 2/16/11, documented Resident #21's [MEDICATION NAME] lock was in the right upper arm, patent and the dressing was dry and intact. The IV Medication Sheet dated 2/17/11 through 2/26/11, lacked documented evidence Resident #21's [MEDICATION NAME] lock site was assessed every shift for redness at the site, complaint of pain or documentation the dressing was changed. The Nurse's Notes dated 2/17/11 through 2/26/11 lacked documented evidence the [MEDICATION NAME] lock site was assessed every shift redness at the site, patency, complaint of pain or documentation the dressing was changed. On 3/31/11 at 1:20 PM, LN #1 was not able to locate documentation the [MEDICATION NAME] lock was assessed for line patency, redness at the site, complaint of pain and dressing changes were done per facility policy. LN #1 stated if a dressing stayed in place for too long the access site could become infected and could go systemic. LN #1 stated if the IV line was not working the medication would not be given into the vein and the area will be swollen. LN#1 stated depending upon the medication if it goes into the tissue and not the vein it can cause tissue damage. Complaint# NV 944

Based on observation, interview and record review the facility failed to have a policy in place for exit door alarms for the secured unit to provide an enviroment free from accident hazzards as possible for one resident (Resident #15). Findings include: Resident #15 Resident #15 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #15 had a history of [REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE], documented Resident #15 had moderate difficulty hearing and her ability to see in adequate light was moderately impaired. The resident had impaired short term and long term memory. Resident #15's cognitive status was moderately impaired. The documentation indicated Resident #15 had lower extremity impairment (hip, knee, ankle, foot) on both sides. The Elopement Risk Assessment form dated 2/8/10, documented Resident #15 was able to propel herself in the wheelchair, but unable to propel herself in the wheelchair long distance. Resident #15 was disoriented/confused, oblivious to needs or safety, non ambulatory, takes medication which may cause confusion, exhibits routine or sporadic confusion, anxiety or disorientation, resistance of anger to placement (e.g. wanting to go home, work or elsewhere), at all times exhibits anxious, pacing behavior (e.g. wandering with no purpose), searching behaviors or looking for exit doors, at all times watching others exit and asking for assistance to leave and a history of elopement attempts. A documented entitled, Updated history and physical examination [REDACTED]. Neurologically Resident #15 moved all extremities and responded to simple questions and commands. Resident #15 had significant impairment of memory and cognitive skills. The current physician's orders [REDACTED]. The current physician's orders [REDACTED]. The facility investigation of the fall revealed Resident #15 had an unwitnessed fall on 3/2/11 at 7:00 AM. The location of the fall was the stairway beside the facility elevators. According to the documentation Resident #15 was wandering at the time of the fall, and required supervision. The resident used a wheelchair as an assistive device. Safety interventions in place were a pad alarm in wheelchair and Wandergaurd. The nurse's notes dated 3/2/11 at 7:00 AM, documented heard door alarm activated. After a through check, was able to locate resident on the stairway. Resident #15 was lying down flat on her back with head partially leaning on the wall and wheelchair on her side. Resident immediately immobilized and complete body assessment done. Resident complained of back pain and two skin tears were noted. Resident was able to move all extremities. Resident alert and orient times one and able to follow commands Documentation from the acute care hospital dated 3/2/11, indicated the chief complaint was mechanical fall and neck pain. The resident came to the acute care hospital because of a fall from 8 concrete steps in the nursing home and an ambulance was called. The documentation indicated Resident #15 was found on her left hand side and complained of pain to her head, right hip and back. No one was with her to see the event. In the emergency room a computerized tomography (CT) scan was done and showed fractures of C2 and T7. Neurosurgery was called and evaluated the resident. The C2 and T7 fractures were nondisplaced. No sign of cord compression. Neurosurgery recommenced placement of a C-collar. The resident was able move both arms and both legs normally. She was alert, awake and disorientated to time and place but she knew her name. On 4/1/11 at 10:15 AM, a tour of the secured unit was conducted with the Unit 3 Manager. A code was required to enter and to exit the unit without setting off the alarm. The secured unit had 2 doors from the dining room area (one with an automatic push button system , the other had to be opened manually) that went out into an enclosed patio area. At the end of a concrete pathway through the patio was an alarmed exit door that lead to an area behind the receptionist and went into the lobby area. The alarmed exit door by room 320 went to the North Parking lot and the alarmed exit door by room 340 exited into the other parking lot. Both doors have the same alarm and code with a 12-15 second delay before the alarms activated when opened. On 4/1/11, during the tour the Unit 3 Manager stated the staff indicated they were not certain just how Resident #15 got to the stairway. The Unit Manager stated Resident #15 probably went down the 309 hallway to the independent dining room. Resident #15 either pushed the door open manually or pushed the automatic door button to open the door that lead into the enclosed patio area. The resident probably activated the door alarm then opened the patio exit door. The alarm was activated on the unit and the nurse's went to the door where the receptionist area was, then down to admissions, checked the stairs and saw Resident #15 on the landing out of the wheelchair. The resident was on her back and partially leaning on the wall with the wheelchair tipped over. The resident went down 8 stairs in the wheelchair. When the resident was found she was alert and complained of back and neck pain. The staff immobilized the resident and 911 was called. On 4/1/11 at 10:40 AM, LN#2 stated Resident #15 made many attempts to open the doors. Everyday the resident thought she was new to the unit and needed to go home. LN #2 stated a few years ago the resident actually eloped from the facility. On 4/1/11 at 10:50 AM, Staff member #4 stated she was on duty the day Resident #15 fell . The staff member stated Resident #15 was up before 6:00 AM, that day and was by the nursing station talking with the nurses. Staff Member #4 stated the alarm went off as she was walking toward the nursing station. Staff Member #4 did not look at the screen/monitor because the "monitor does not tell which door was alarming". Staff member #4 verbalized she went down the hallway to the independent dining room and through the patio area. The patio exit door was alarming, and she did not see the resident. Staff member #4 indicated LN #3 went down the hallway past the television room, out the secured exit door, looked in the hallway, then went into the lobby area. The front doors were locked and no one was in the lobby area. The LN went down the hall to the elevator and no one was there. LN looked in the window located in the stairway door, opened the door and saw Resident #15 on the landing of the stairway. On 4/1/11 at 11:15 AM, Licensed Nurse (LN) #3 stated Resident #15 had been up at 6:00 AM around the nurse's station and around 7:00 AM she heard an alarm (the sound was a steady eee sound like an oxygen concentrator when it was first turned on). The LN stated she went passed the television room, the northwest exit and realized the back patio door was "going on", heard the door alarm and went to the lobby doors which were locked. No one was in the lobby area, she went down the hallway to 200 hallway and did not see anyone there. LN #3 opened the door by the elevators and saw Resident #15 lying flat in the stairway on the landing. Resident #15 was on her back with her head leaning on the wall. Resident #15 was alert, awake and talkative. The wheelchair was by the resident's left leg and in an upright position. The wheelchair pad alarm was going off and the Wanderguard was in place. LN #3 stated it took 3-5 minutes to find Resident #15. On 4/1/11 at 11:40 AM, the Director of Environmental Services and the surveyor walked from the stairway by the elevators to the patio door, from the patio door through the patio area to the independent dining room area door, and from the independent dining room door to the nursing station where Resident #15 was last seen by staff. The Director of Environmental Services paced off the steps along the route the facility staff felt Resident #15 had traveled, while the Surveyor timed the route. The route took approximately 3 minutes and 40 seconds and the area of the route was approximately 245 paced steps. During the interview on 4/1/11, the Director of Environmental Services stated the staff had told him after the event they could not hear the alarm to tell where it was coming from, so an extra speaker was put in place. He stated a form was made to assist staff to determine which alarm was sounding and the location. On 4/1/11 at 12 Noon, the Director of Environmental Services and the facility Administrator stated the facility did not have a policy on what staff were to do when the exit doors alarmed. On 4/1/11 at 1:45 PM, Staff member #5 stated around 6:30 -6:40 AM, she was going down stairs and heard some one scream and "go bump, bump, bump". She and a Respiratory therapist looked in the stairway window but could not see anything. They opened the door an saw Resident #15 on the landing with the wheelchair on top of her and LN #3 was with her. Staff member #5 stated Resident #15 was on her right side with the wheelchair on her leg or just on her. LN #3 was holding her head. Staff member #5 verbalized the resident was screaming in pain. CPT # NV 714